Elmira Business Institute

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Personal Data

First Name:

Last Name:

Middle Name:

Maiden Name:

Address:

City:

State:

Zip Code:

Hm Phone:

Wrk Phone:

Email:

Date of Birth:

Name & Phone Number of person to be contacted in case of emergency:

Any physical and/or medical disabilities that require special assistance:

Educational Plans For Attending EBI

I desire to enroll in (please check one):

Fall Term Spring Term Summer Term

I am applying for:

Day Division Evening Division

Please indicate year of entrance:

Associate Degree Programs:

Accounting
Medical Assisting
Office Technologies Medical
Office Technologies Legal
Medical Coding & Reimbursement Specialist

Certificate Programs:

Legal Office Assistant
Medical Office Assistant
General Business Accounting
General Office Assistant
Medical Assisting
Medical Coding & Billing

Educational Data

(Request your Guidance Counselor to send us your High School transcript immediately)
(If you earned an equivalency diploma, please provide us with a copy of your test scores)

High School Attended:

City & State:

Dates Attended:

Date Graduated:

GED Location:

City & State:

Dates Attended:

Date Graduated:

College Attended:

City & State:

Dates Attended:

Date Graduated:

Will you request transfer credits from the above college? (Indicate Yes or No):
(If yes, please request each college to send us your official transcript and course description for evaluation.)

Educational Data

Employer:

City & State:

Dates Employed:

Type of Work:

Employer:

City & State:

Dates Employed:

Type of Work:

Employer:

City & State:

Dates Employed:

Type of Work:

How did you learn about EBI?

(Please place an X in box that applies.)

Relatives who attended:

High School Guidance Counselor/Teacher:

EBI Presentation in High School:

College Fair:

Open House:

Received Mailer:

EBI Admissions Rep:

Other (explain):

Recommendation of EBI Graduate:

Recommendation of Present EBI Student:

Newspaper Ad (Specify newspaper):

TV Ad (Specify station):

Yellow Pages:

Business Referral (Specify business):

Government Sponsored Prog.:

Radio Ad (Specify station):

Two References (Not Relatives)

Name:

Address:

City:

State:

Zip Code:

Phone:

Name:

Address:

City:

State:

Zip Code:

Phone:

I hereby verify that all information provided on this form is true and accurate.

I hereby apply for admission to Elmira Business Institute. I understand that in addition to this application, an interview with an admissions representative is required for acceptance. If accepted, I agree to abide by the rules and regulations of the college as stated in the EBI Catalog and Student Handbook.

I accept the above statement

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