Student Application 2023

Application Information

First Name (required)

Last Name (required)

Middle Initial

Date (required)

Street Address (required)

Apartment/Unit #

City (required)

State (required)

Zip Code (required)

Phone (required)

Email address (required)

Date Available

Social Security Number

Which Class Are You Applying For? (required)

Are You A US Citizen? (required)

Yes

Have you working in the automotive industry before? (required)

Yes

If Yes When? (required)

Have you ever been convicted of a felony? (required)

Yes

If yes when? (required)

Education

High School (required)

High School Address (required)

College

College Address

References

Reference 1 Full Name

Reference 1 Company

Reference 1 Relationship

Reference 1 Phone

Reference 2 Full Name

Reference 2 Company

Reference 2 Relationship

Reference 2 Phone

Reference 3 Full Name

Reference 3 Company

Reference 3 Relationship

Reference 3 Phone

Previous Employment

Company

Address

Supervisor Phone Number

Job Title Responsibilities

Start Date

End Date

Reason for Leaving

Can we contact your previous supervisor for reference?

Yes

Military Service

Branch

From Date

To Date

Rank at Discharge

Type of Discharge

If other than honorable please explain

Disclaimer and Electronic Signature

I certify that my answers are true and complete to the best of my knowledge. If this application leads to enrollment, I understand that false or misleading information in my application or interview may result in my release

Signature (Print Name)

Date Signed

If grants or sponsorships are available, are you interested in them?

Yes

Autoseum.org Automotive Teaching Museum

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Mike Manning

mike@autoseum.org

President