You can print the application below, fill it out and return to the following address

William R. Moore College of Technology
1200 Poplar Ave
Memphis, TN 38104

Or download the application in Microsoft Word format here...

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William R. Moore College of Technology

1200 Poplar Ave. Memphis, TN 38104-7240 Phone 901-726-1977

Non-Profit - Established 1939 - www.mooretech.org

Application for Admission

Name _________________________________ ________________________ ________________

Last First Middle

Social Security # ________________________ Home Phone _______________ Other Phone ______________

Address: _________________________________________________________ __________________

Street Apt. No.

_____________________________ _____________________________ ________ ______________

City State Zip Code

Emergency Contact: Name __________________________________________ Phone _____________________

Check the program for which are you applying. Check Only One:

Air Conditioning, Ref. & Heating _____ Computer Operation & Repair _____ Industrial Electricity _____ Machine Shop _____ Property Maintenance _____ Welding _____

Day students list course electives _____________________________________________________

Trimester of Enrollment: Fall ___ Winter ___ Spring ___ Year __________

Check type of enrollment

Full-time (5days wk) ____ Half-time (5days wk) ____ Mon-Wed (2nights wk) ___Tu-Th (2nights wk)____

9:00 am-3:30 pm 9:00 am to 12:00 pm 6:30 pm to 9:00 pm 6:30 pm to 9:00 pm

or 12:30 pm to 3:30 pm

Employer _______________________________________________________________________ Address_______________________________________________________ Phone __________________

Job Title _________________________________ Work Hours __________________________

Is your employer paying for your training? _____ If yes, please provide a letter from your employer.

Sex: M___ F___ Date of Birth _______________ Place of Birth _______________________________

Ethnic Origin: Asian ____American Indian ____ Black/African-American ____ Hispanic ____ White ____

Citizenship: Are you U.S. Citizen? yes __ no __ If no, Country of Citizenship ___________________________

Visa type or Resident Alien # ___________________________ Visa/Passport Expiration Date _______________

College Goal Check One: Associate Degree (Day Only) _____ Day Diploma _____ Night Certificate _____

Career Change _____ Personal Enrichment _____ Upgrading Job Skills _____ Other ___________________

please complete the back of this application

Have you ever been convicted of a felony? Yes___ No ___ If yes, list all offences and dates

____________________________________________________________________________________

Are you now on probation from a conviction? Yes___ No ___ Date Probation Ends _____________

How did you hear about our college? ______________________________________________________

Are you applying for the Federal Financial Aid (PELL grant) available to qualified day students? ____

Have you ever received Federal Financial Aid (PELL grant or loan)? ____

Are you in default on a Federal grant overpayment or a Federally subsidized loan? ____

If yes, provide details___________________________________________________________________

____________________________________________________________________________________

Are you a U.S. military veteran? ____ Do you plan to apply for VA educational benefits? _____

Do you plan to attend through Vocational Rehabilitation? ___ If yes, counselor’s name ______________

Check here if you do not want our free job placement services after graduation ____

Have you been offered one of our catalogs? yes _____ no _____

Have you previously attended our college? ____ If yes, when? _________________________________

What name did you use when you attended? ________________________________________________

Did you graduate from High School? ____ If yes, year of graduation:____________________________

Name of High School: ____________________________ Location:_____________________________

Your name as listed on the high school transcript: ___________________________________________

If you did not graduate you must have a GED. When did you receive your GED? ________

You must provide the college a certified copy of your high school transcript or GED.

List All Colleges or Universities you have attended:

Name of College or University City State Dates Attended Degree Earned

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

I authorize William R. Moore College of Technology (MOORE TECH) to obtain a consumer report during the application process or at any time during my enrollment. I understand this report may include information regarding character (criminal record) and personal characteristics.

I certify the information on this application to be true and complete. I understand giving false information or withholding information may make me ineligible for admission or may result in my dismissal.

Signature __________________________________________ Date ____________________________

Release of Private Information:

No student information will be released without authorization from the student. The only exception is for dependant PELL students. Grades and attendance records for dependant PELL students can be released without student authorization to their parents or legal guardians.

Application Statement of Procedure: All application and related documents become property of the institution and cannot be forwarded or returned. These documents are maintained in the active files for a 12-month period. After this period a new application must be submitted. In compliance with the College and University Security Information Act. A campus crime report is made available to each enrolling student upon request and is posted on the student information bulletin board.

Rev. 05-08 Visit our web site http://www.mooretech.org