Allegheny Valley Institute of Technology^®

APPLICATION FORM

Name:   Last  ________________________  First  __________________  MI  _______ 

Home Phone: (     )   _______________________  Social Security Number  ____________________

Work Phone (if applicable):  (     )  _________________________ 

Date of Birth:  _____________  Sex:  Male  Female

U. S. Citizen   Yes  No   If no, country of citizenship:  __________________

Ethnic Origin:  _______________ (Voluntary)

Local address (including zip code) _________________________________________
______________________________________________________________________
______________________________________________________________________

Permanent address (including zip code) _____________________________________
_______________________________________________________________________
_______________________________________________________________________

Internet (e-mail) address: _________________________________________________

Program of Study applying for:: __________________________________________  

Academic Achievements:

High School Diploma?  Yes  No   If no, please provide GED Score:___________

References of at least three individuals who can validate your interest in computer technology:

Name                                                                                                                 Phone

1.______________________________________________________________________

2.______________________________________________________________________

3.______________________________________________________________________

I certify that all information contained in this application is correct and complete to the best of my knowledge. I understand that withholding and/or giving false information on this application may make me ineligible for admission or later subject to dismissal. If admitted to the Allegheny Valley Institute of Technology^®, I agree to abide in accordance with the regulations of the institution as explained in the School Catalog and Student Guide. 

Applicant Signature _____________________________   * Application Fee Enclosed 

Date:  _____________________________

Parent’s Signature and accompanying information is required if the applicant is less than 18 years of age:                                                

Parent Signature:  _____________________________   Date: _____________

Address: _____________________________

                   _____________________________

Phone Number: _____________________________            

*An Application Fee of $35 must be submitted with this application.  If you mail this application, enclose a check or money order made payable to the Allegheny Valley Institute of Technology and send it to the Admissions Office.  The entire fee will be refunded if the applicant is found to be ineligible or not acceptable for admission.  This fee is not refundable after five calendar days have elapsed. The Allegheny Valley Institute of Technology reserves the right to accept or reject any applicant.

Please return Application Form to:

Allegheny Valley Institute of Technology
1 Kiski Avenue, Leechburg, PA  15656
Attention: Admissions