February 23, 2012

Medical Career Training

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Online Application

DBI Downriver Online Application

First Name:*
Last Name:*
Middle Initial:
Address:
City:
State:
Zip Code:
Email Address:*
Primary Phone:*
Secondary Phone:
Date of Birth:
MM
DD
YYYY
Educational Background
Current Status:
- High School Graduate
- GED Recipient
- High School Student
Graduation/GED Date:
MM
DD
YYYY
Name of High School:
City and State:
Additional Education
Name of School 1:
City and State (School 1):
Dates Attended (School 1):
Name of School 2:
City and State (School 2):
Dates Attended (School 2):
Marital Status:
- Single
- Married
- Divorced
- Widowed
Are you a U.S. Citizen?
- Yes
- No
Are you a Veteran?
- Yes
- No
If yes, date of discharge:
MM
DD
YYYY
Do you have any health difficulties for which we need to be aware?
- Yes
- No
If yes, please describe:
Are you employed?
- Yes
- No
If yes, Employer Name:
Employer Phone:
Program of Study:
- Medical Assistant
- Medical Office
- Practical Nurse
Do you plan to attend classes:
- Day
- Evening
All applicants to Detroit Business Institute-Downriver are required to complete a personal interview with an admissions representative. Appointments are available on Mondays and Wednesdays from 8:30 a.m. to 4:00 p.m.; Tuesdays and Thursdays, 11:00 a.m. to 6:30 p.m.; and on Friday, 8:30 a.m. to 3:00 p.m. Please indicate a convenient date and time to meet with an admissions representative:
Interview Date:
Interview Time:
: HH
MM
By submitting this application, I certify that the information in this application is complete and accurate to the best of my knowledge.

DBI Downriver

19100 Fort Street
Riverview, MI 48193-6799
(734) 479-0660

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