Online Application

Please fill out the information requested below. Required fields are in bold.

I. PERSONAL INFORMATION
Name:
Social Security Number:
Address:
Postal Code:
City/State:
County:
Telephone:
	Please enter your telephone number as ###-###-####
Date of Birth:
	Please enter your birth date as MM/DD/YYYY
Email Address:
How did you hear about the program:
Please state your disability:
Please state your disability (if more than one):
If disability is visual, please state the cause and visual acuity and/or visual fields if known:
If visually impaired, what is your preferred method of receiving information? Regular print Large print Braille CD Other
If large print is preferred, please specify font size (if known):

II. EDUCATION AND TRAINING
High School:
Dates Attended:
Graduated: Yes No

College/University:
Dates Attended:
Graduated: Yes No
Degree:

Other Education:
Dates Attended:
Graduated: Yes No
Degree:

Foreign Language:
Foreign Language Skills: Read Write Speak

Computer Experience: Yes No
If yes: Windows DOS
List any machines or equipment you can operate:
Do you use any of the following adaptive software? Zoomtext JAWS
If you have used other adaptive software, please describe:
Have you ever participated in a job readiness training program or workshop? Yes No
If yes, where:
Did you successfully complete the program? Yes No
If no, please explain:

III. EMPLOYMENT EXPERIENCE
Please list your most recent job history (use additional sheets if necessary). Start with your present status and note any periods in which you were not employed. Include U.S. military service, summer/part-time jobs, and cooperative education assignments.

1. Employer Name:
Address:
Phone Number:
Employment Start Date:
Employment End Date:
Rate of Pay:
Title:
Job Description:
Reason for Leaving:
May we contact this employer? Yes No

2. Employer Name:
Address:
Phone Number:
Employment Start Date:
Employment End Date:
Rate of Pay:
Title:
Job Description:
Reason for Leaving:
May we contact this employer? Yes No


3. Employer Name:
Address:
Phone Number:
Employment Start Date:
Employment End Date:
Rate of Pay:
Title:
Job Description:
Reason for Leaving:
May we contact this employer? Yes No

If you have ever been terminated or asked to resign from any position, please explain:

IV. ENTRANCE DATE
I am applying for admission to the term beginning: February May September
Please write a paragraph explaining your interest in this program:

V. EMERGENCY CONTACT INFORMATION
Emergency Contact Name:
Emergency Contact Relationship:
Emergency Contact Phone:
Health Insurance Provider:

ADDITIONAL INFORMATION:
If you currently have an open case with a state or non-profit agency (such as V.E.S.I.D. or the Commission for the Blind and Visually Handicapped) please include the following information:

Name of state or non-profit agency with which you have an open case:
Agency Address:
Counselor:
Counselor Phone:

Have you ever been convicted of a crime? Yes No
If Yes, provide details:

Please include two business, academic, and/or personal letters of recommendation.

Mail your letters of recommendation to:

Attn: Chaunci Hinton

National Statler Center

1160 Main Street

Buffalo, NY 14209