AECC Admissions Application

ADMISSIONS APPLICATION

AECC Career School
300 S. Spring, Suite 300
Little Rock, AR 72201
501-615-8922

STUDENT INFORMATION
Student Name:		Social Security Number:
Address:		City/State/Zip:
Telephone:
E-mail Address:
Education:	Name of High School Completed: City/State:
Education:	Name of College Attended: City/State:

Program Request
Program Name:
Course Length:	Contact Hours:	Date the training is to begin:
Course(s)		Business Skills Training Program
Pre-Employment Career Readiness Training Program		Microsoft Applications: Office 365-Outlook:
Customer Service Skills Training Program		Microsoft Applications: Data Entry- Word 365, Level I
		Microsoft Applications: Data Entry- Excel 365, Level I
Certified Nursing Assistant (CNA)		Microsoft Applications: Office 365-Power Point
Certified Pharmacy Technician (CPhT)
*Total Cost is estimated and based on current cost and subject to change.

TOTAL COST: $

1

Method of Payment (check one)

Money Order

Cashier Check

Cash

Other

[If interest is charged or more than three payments are allowed, state the terms. If no interest is charged, so state]

“Any holder of this consumer credit contract is subject to all claims and defenses which the debtor could assert against the seller of goods or services obtained pursuant hereto or with the proceeds hereof. Recovery hereunder by the debtor shall not exceed the amounts paid by the debtor hereunder. “

Refunds are applicable according to State Board of Private Career Education Rules and Regulations and AECC guidelines.

(i) At completion of less than twenty-five percent (25%) of the program, the refund shall be made on a pro rata basis.
(ii) At completion of 25% but less than 50% of the program, the student shall be refunded not less than 50% of the tuition.
(iii) At completion of 50% but less than 75% of the program, the student shall be refunded not less than 25% of the tuition.
(iv) At completion of 75% or more of the program no refund is due the student
.

Licensed by the Arkansas Division of Higher Education.

Name of Student (Print)

Date

Signature of Student

Printed Name of Authorized AECC Official

Date

Signature of Authorized AECC Official

Updated: 4/20/21

2

BACKGROUND INFORMATION SECTION

To ensure that these criteria are evaluated before appointments are made, all applicants must complete this application and agree to a background check. Any information contained on the application is strictly confidential, except that it is subject to the Privacy Notice, as printed in this application.

Full Name (first, middle, last)

Current Mailing Address

Current Phone NumberSocial Security # (required)

Previous Names Used

Date of Birth (required)Place of BirthSexM F

Have you ever been convicted of a felony, misdemeanor or ordinance violation? Yes No

Do you have pending court charges for a felony, misdemeanor or ordinance violation? Yes No

CONSENT TO RELEASE INFORMATION

I hereby authorize all parties named in this application to disclose information to Arkansas Employment Career Center any information necessary to determine eligibility information regarding my character. I hereby release the parties from all liability that may arise from furnishing such information.

All information in this employment application are true and accurate to the best of my knowledge and I agree to terms set forth.

Applicant SignatureDate

ARKANSAS STATE POLICE

Identification Bureau

Individual Record Check Request Form

ASP 122

Last Name	First Name	Middle Name	Jr./Sr./III
Daytime Phone #:
List ALL other names ever used (married, maiden, shortened, etc.)
Date of Birth:	State of Birth:	Race:	Sex:
Social Security #:		Driver’s License #:
Mailing Address: Street/P.O. Box City State Zip Code

APPLICANT RECORD NOTICE

Obtaining Copy: Procedures for obtaining a copy of the FBI criminal history record are set forth Title 28, Code of Federal Regulations (CFR) Section 16.30 through 16.33 or the FBI website at http://www.fbi.gov/about-us/cjis/background-checks.

Change, Correction, or Updating: Procedures for obtaining a change, correction, or updating of an FBI criminal history record are set forth in Title 28, Code of Federal Regulations (CFR), Section 16.34.

I give my consent for the Arkansas State Police to conduct a criminal record search on myself and release any results to the following person or entity:

Signature:Date:

Release to:

Mailing Address:

WHEN THIS PROPERLY COMPLETED REQUEST FORM IS SUBMITTED {OTHER THAN IN PERSON BY THE SUBJECT OF THE CHECK} THIS REQUEST FORM MUST BE NOTARIZED

STATE OF

COUNTY OF

Subscribed and sworn before me, a Notary Public, in and for the county and state aforesaid, this is the day of , 20 .

Notary Public

BELOW FOR OFFICE USE ONLY

82005 State Record Check
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Arkansas Employment Career Center
Little Rock Arkansas
300 S. Spring Street, Suite 300
72201