Center for Professional Development

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IT Certificate Program Application

Personal Information  
Name: Last:  First:  Middle Initial:
Birthdate MM/DD/YYYY: Email Address:
Current Mailing Address:
City: State:  Zip:
Home Phone:     Business Phone:    Fax:  
Check here if you are an international applicant

Computer Experience and Education
How many years of computer experience do you have overall?   Years
Operating System Experience: Please indicate the number of years experience you have with each operating system and whether the experience was primarily on the job, in a school program, or at home.
     Operating System   / Number of Years / Nature of Experience
PC-DOS Work   School   Home
Windows XP/Vista Work   School   Home
Macintosh Apple-DOS Work   School   Home
Macintosh OS-X Work   School   Home
OS/2 Work   School   Home
UNIX (Any Vendor) Work   School   Home
Linux Work   School   Home
Other: Work   School   Home
Programming Languages: Please indicate the number of years of programming experience.
     Programming Language   / Number of Years  / Nature of Experience  /
Work School Home
Work School Home
Work School Home
Education: Please list, in chronological order, all colleges or universities attended since graduating from high school.
Undergraduate Institution Location Dates Attended Major Degree Awarded Date/Expected Date
of Degree

Graduate, Diploma, or
Certificate Program
Location Dates Attended Major Degree Awarded Date/Expected Date
of Degree

Work Experience: Please  list each full or part-time position you have held.
Employer Address Job Title Employment Dates

Additional Information and Signature
For what do you regularly use a computer? (Check all that apply)
Application Programming Desktop Publishing Software Development
Accounting Project Management Systems Management
CAD/CAM Spreadsheets Web Development
Databases Other
Will your employer sponsor you in the program? Yes   No
Will your employer offer tuition assistance? Yes   No
 If not, how will you pay for the program?

How did you hear about the program? (i.e. Trib-Business, Internet, friend, etc.)

What is your career objective in enrolling in this program?

Signature: Please enter your name as you usually sign it

Illinois Institute of Technology admits students of any race, color, sex, handicap, or national ethnic origin to all the rights, privileges, programs, and activities generally made available to students at the school. IIT does not discriminate on the basis of race, color, sex, national ethnic origin, or handicap in the administration of its educational policies, admissions policies, scholarship and loan programs, and athletic or other school-administered programs.