Application For Admission
Kansas Braille Transcription Institute
250 S. Laura
Wichita, Kansas 67211
(316) 265-9692
(316) 265-0184 (fax)
info@kbti.org

Personal Information
Date of application:
First
Street
Apt
Zip:
Phone
E-mail
SS Number:
  
Occupation Information
Please list your last three employers, beginning with the current/most recent
Employer # 1 Name:
Address:
City:
State:
Zip Code:
Position held:
Primary Duties:
Supervisor's name:
Hours per week:
Starting pay:
Ending pay:
Start date:
End date:
Reason for leaving:
  
 Description of primary disability:
 Date of onset of disability:
 Resulting limitations:
 Description of secondary disability:
 Resulting limitations:
Do you need any accomodations?
If yes, describe
 
Educational Information
Name on school records:
 
Diploma/Degree
Major/Course Work
Highest Level Completed
 
 
 
 
Where GED obtained:
Date GED obtained
Special Skills/Qualifications
Have you ever been convicted of any isdemeanors or felonies within the last 7 years?
If yes please complete the following: Date
Location
Charge
Action taken
  
Reference Information
Please list two references that have direct knowledge of you and your work:
Name: Address: Telephone number:
Name: Address: Telephone number:

Please read the following statements. They will constitute the conditions under which you will be accepted for training:

1. The information I have provided is accurate to the best of my knowledge and subject to    validation by the Kansas Braille Transcription Institute Computer Training Program.

2. I authorize the persons, schools, law enforcement agencies and other organizations or    employers named to provide the Kansas Braille Transcription Institute Computer Training    Program with any relevant information that may concern my acceptance for training.

3. I understand that false or withheld information could lead to rejection or termination from    the program.

4. I understand that I may be required to pass a drug test prior to acceptance into the     program and that there may be random drug tests conducted during the training     program.