Digital Media Institute at InterTech Application

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Program (Please select from the dropdown menu)*

Animation, Visual Effects & Interactive Content (Spring Session)Animation, Visual Effects & Interactive Content (Fall Session)Interactive Software Development

Please give us a little information on why you are interesed in the program.*

First Name*

Last Name*

Address 1*

Address 2

City*

State*

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Zip / Postal Code*

Email*

Phone*

Date of Birth*

Gender* Male Female

Ethnic Origin

American Indian or Alaskan NativeAsian or Pacific IslanderBlack or African AmericanHispanic or LatinoWhite

Emergeny Contact (Name, Phone, Relationship)

How did you hear about us? *

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High School (Name, City, State & Graduation Date OR GED Score & Date Completed)*

Are you currently attending a college or university? If so, please name the institution below.

Have you ever been suspended, dismissed or placed on probation at any college or university for scholastic or disciplinary reasons? If so, please give the name of the institution and reasons below.*

Please list any college previously attended, dates attended and degree/certificate received (whether credits were received or not)

Have you ever been convicted of a felony? If so, please list the date and charge below.*

Do you have a military background?

Yes No

If you answered yes, please list which branch you served under.

Briefly describe your employment history.*

DMII is committed to equal access for all students and to providing an environment in which learning is done in a comfortable and welcoming space. If you have any conditions you would like to voluntarily disclose that you think may inhibit your ability to participate in the program, please list them below. DMII provides reasonable accommodations to students with disabilities. Students are not subject to any adverse treatment as a result of disclosing this information nor will we release any information without your consent.

I certify that all information on this application is correct and any false information may make me ineligible for admission. This is a general application and more information may be requested via phone or in person.*