Admission Form

Select your Degree Program

Other

Applicant Section

Date

Applicant Name:

Last *

First *

Middle

Home Address:

Street and Number

City/Town

State

Zip Code

Home Phone #

Email *

Date of Birth

Social Security

Gender

Female

Male

Country of Birth

Educational History:

High School/Secondary Information

Schools

Locations

Completion Dates

Degrees

School 1

School 2

School 3

College/University Information

Schools

Locations

Completion Dates

Degrees

College 1

College 2

College 3

Send official transcripts to the Admissions Office, Emiraza College, 510 South US Highway 1, Fort Pierce, FL 34950

PROVIDE STATE AND LICENSE NUMBER(S):

Have you ever been incarcerated or convicted of a felony, or have you experienced disciplinary problems at another educational institution?

Yes

No

If yes, please submit a written statement detailing the circumstances to the dean of students for review prior to admission to Emiraza College. This information will be handled confidentially

SIGNATURE SECTION

The statements and information furnished by the undersigned in this application form are true and complete. Our signatures certify that we have read and agree with the above statements.

Signature of Student *

Date