HEOSI Application

REQUEST INFO PACKET

Heavy Equipment Operators School of Idaho

Course Application Form

Student Information

First Name *
Middle Name
Last Name *
Address *
City *
State *

Zip *
Country *
Phone *
Email
Emergency Contact *
Emergency Phone *

Biographical Information

Sex

Ethnicity

(This information is requested for statistical purposes )

Enrollment Information

What is the highest level of education you obtained? *
Name of school where highest level of education obtained? *
City of school where highest level of education obtained? *
State of school where highest level of education obtained? *

Residency Status

Citizenship *
Type of Visa		Date Issued
Country of origin

Are you a legal Idaho resident?: *
If yes, date present stay in Idaho began (mm/dd/yyyy):
If no, Most recent state of legal residence prior to moving to Idaho:
What date did you leave that state (mm/dd/yyyy):

Personal Information

1. Is your driver's license currently expired, suspended, not valid or without a picture? *
2. Have you ever been convicted of a felony for use or posession on an illegal drug? *
3. Have you used an illegal drug in the last 6 months? *
4. Would you object to taking a drug test paid for by the school? *
5. Do you speak English as a second language or have any difficulty speaking English? *
6. Are you a NON-United States Citizen? *
7. Do you have uncorrectable (worse than 20/40) vision in either eye? *
8. Do you have a history of epilepsy, diabetes or seizures? *
9. Have you ever had a back injury or back surgery, or limitaitons of movement? *
10. Are you currently taking and prescription medications? *
11. Are you on medication for, or do you have a history of mental illness? *
12. Do you have a hearing impairment? *
If you answered yes to any of the above questions, identify each corresponding number (1-12) followed by an explanation.