LAVI Application Developer

Personal Information

(Provide your legal name and contact details as they appear on official identification.)

Full Name (Last, First, Middle Initial)

Date of Birth (MM/DD/YYYY)

Social Security Number (if applicable)

TIN Number

Resident ID Number

Mailing Address

City

State/Province

Zip/Postal Code

Email Address

Daytime Phone

Evening Phone

Current Occupation (if employed)

Gender

Male Female Other/Prefer not to say

Emergency Contact (Name, Relationship, Phone)

Programme of Study

Please select the course you are applying for. You may only select one.

Massage Therapy Physical Therapy Aide Certified Nursing Assistant (CNA) Home Health Aide (HHA)

Medical Coding and Billing Medical Assistant NCLEX-RN Preparation Phlebotomy Pharmacy Technician

Class Schedule Preference:

Days Evenings Weekends

How did you hear about LAVI?

Direct Referral CANIN | moneyIN Global | US Business Gateway Inc.

Online Search Social Media

Education History

High School

High School Attended:

Location:

Status:

Graduated Received GED Did not complete

College / University

College/University Attended (if any):

Location:

Dates Attended:

Degree/Certification (if awarded):

Other Qualification

Qualification Type:

Skills & Background Assessment

This section helps us understand your strengths and support needs.

Languages spoken:

Computer literacy:

Beginner Intermediate Advanced

Healthcare or vocational experience (if any):

Career goals:

Do you require additional learning support (e.g. English language, study skills)?

Yes No

Dependent Information (if applicable)

If you have dependents (spouse, children) who may require visa assistance, please complete this section. Otherwise, leave blank.

Spouse’s Full Name:

Date of Birth:

Children’s Full Names and Dates of Birth:

Emergency Contact Information

Person 1 - Full Name:

Relationship:

Email:

Contact Number (including country code):

Person 2 - Full Name:

Relationship:

Email:

Contact Number (including country code):

Previous Training & Experience

Please describe any previous training, certificates, or experience related to your chosen programme.

Supporting Documents

Please attach/upload the following:

High school transcript or GED certificate:

College/university transcript and certificate (if applicable):

Copy of valid photo identification (passport, driver’s license, or Local ID):

Any professional certificates (if relevant):

Passport Size Recent Photo:

I confirm that I have attached/uploaded all required documents.

⚠️ Applications will only be reviewed once the $500 USD non-refundable deposit has been paid and confirmed.

Health & Wellness Information

Please provide accurate health and wellness information.

Do you have any communicable diseases? (A physical may be required.)

Yes No

Have you had any communicable diseases in the last two years?

Yes No

Are you currently taking or have you taken any medications in the last two years?

Yes No

Please let us know of any mental or physical condition that might affect your participation in school activities. Attach a separate sheet if needed.

Consent & Acknowledgements

By submitting this application:

I consent to LAVI processing my personal data in accordance with applicable privacy and data protection laws.

I understand that electronic signatures are binding and enforceable.

I agree to comply with all policies, rules, and regulations of LAVI.

I grant permission to LAVI to use my photograph or video for educational and promotional purposes:

Yes No

I acknowledge that applications will not be processed until the $500 USD non-refundable deposit has been received.

I authorize communication of my application details to approved referral partners such as CANIN and moneyIN Global, where applicable.

Declaration

I certify that the information provided in this application is accurate and complete to the best of my knowledge. I understand that providing false information may result in denial of admission or dismissal from the programme.

Applicant’s Full Name (Electronic Binding):

Date:

Los Angeles Vocational Institute

Education Services - Application for Admission

Personal Information

Programme of Study

Education History

High School

College / University

Other Qualification

Skills & Background Assessment

Dependent Information (if applicable)

Emergency Contact Information

Previous Training & Experience

Supporting Documents

Health & Wellness Information

Consent & Acknowledgements

Declaration