Creating Futures

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1. Please briefly describe your technology background.

Please briefly describe your technology background.

2. Are you a military veteran?

Are you a military veteran?   Yes No

3. Do you have a disability rating?

Do you have a disability rating?   Yes No

4. Are you currently employed?

Are you currently employed?   Yes No

5. Are you currently enrolled in higher education?

Are you currently enrolled in higher education?   Yes No

6. Do you currently hold any technology certifications?

Do you currently hold any technology certifications?   Yes No

7. Are you interested in an information technology career?

Are you interested in an information technology career?   Yes No

8. Have you ever taken a class online before?

Have you ever taken a class online before?   Yes No

*

9. Your contact information:

Your contact information:   Name:
Address:
Address 2:
City/Town:
State:	-- select state --AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming
ZIP/Postal Code:
Email Address:
Phone Number:

10. Additional Information:

Additional Information: