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Written Exam Registration Form

Approved by Miami-Dade and Broward Counties

This form may be reproduced if extra copies are needed.

Important: Read this form first and then print the required information neatly.

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@if($sessionConfig)

REGISTER BY {{ $sessionConfig->register_by_date ? $sessionConfig->register_by_date->format('m/d/Y') : 'N/A' }}

{{ $sessionConfig->limited_space_text }}
{{ $sessionConfig->exam_day }}, {{ $sessionConfig->exam_date ? $sessionConfig->exam_date->format('F j, Y') : 'N/A' }}
Initials: {{ $sessionConfig->initials }} {{ $sessionConfig->exam_time }}
@endif
Personal Information
Social Security Number {{ $registration->ssn ?? 'N/A' }} Home Telephone {{ $registration->home_phone ?? 'N/A' }}
Date of Birth {{ $registration->date_of_birth ? $registration->date_of_birth->format('m/d/Y') : 'N/A' }} Cellular Telephone {{ $registration->cellular_phone ?? 'N/A' }}
Email {{ $registration->email ?? 'N/A' }} Work Telephone {{ $registration->work_phone ?? 'N/A' }}
Last Name {{ $registration->last_name ?? 'N/A' }} First Name {{ $registration->first_name ?? 'N/A' }}
Middle Initial {{ $registration->middle_initial ?? 'N/A' }} Sex {{ $registration->sex ? ucfirst($registration->sex) : 'N/A' }}
Mailing Address {{ $registration->mailing_address ?? 'N/A' }}
City {{ $registration->city ?? 'N/A' }} State {{ $registration->state ?? 'N/A' }}
ZIP Code {{ $registration->zip_code ?? 'N/A' }}
Race/Ethnicity @if($registration->race_ethnicity) {{ ucfirst(str_replace('_', ' ', $registration->race_ethnicity)) }} @if($registration->race_ethnicity_other) ({{ $registration->race_ethnicity_other }}) @endif @else N/A @endif
Education
Grade School / High School {{ $registration->grade_school ?? 'N/A' }} Trade or Technical School {{ $registration->trade_school ?? 'N/A' }}
College {{ $registration->college ?? 'N/A' }}
Language & Testing Center
Language {{ $registration->language ? ucfirst($registration->language) : 'N/A' }} Testing Center {{ $registration->testing_center ? ucfirst(str_replace('_', ' ', $registration->testing_center)) : 'N/A' }}
Exam Selection
Certification Re-Cert. Certification Re-Cert.
@if($registration->ac1_cert) ✓ AC1 Auto: Engine Repair @else ○ AC1 Auto: Engine Repair @endif {{ $registration->ac1_recert ? 'X' : '-' }} @if($registration->tc12_cert) ✓ TC12 Med/Hvy Truck: Engine Repair/Gasoline/Diesel @else ○ TC12 Med/Hvy Truck: Engine Repair/Gasoline/Diesel @endif {{ $registration->tc12_recert ? 'X' : '-' }}
@if($registration->ac2_cert) ✓ AC2 Auto: Engine Performance @else ○ AC2 Auto: Engine Performance @endif {{ $registration->ac2_recert ? 'X' : '-' }} @if($registration->tc13_cert) ✓ TC13 Med/Hvy Truck: Drive Trains @else ○ TC13 Med/Hvy Truck: Drive Trains @endif {{ $registration->tc13_recert ? 'X' : '-' }}
@if($registration->ac3_cert) ✓ AC3 Auto: Brakes @else ○ AC3 Auto: Brakes @endif {{ $registration->ac3_recert ? 'X' : '-' }} @if($registration->tc14_cert) ✓ TC14 Med/Hvy Truck: Brake/Braking Systems @else ○ TC14 Med/Hvy Truck: Brake/Braking Systems @endif {{ $registration->tc14_recert ? 'X' : '-' }}
@if($registration->ac4_cert) ✓ AC4 Auto: Suspension & Steering @else ○ AC4 Auto: Suspension & Steering @endif {{ $registration->ac4_recert ? 'X' : '-' }} @if($registration->tc15_cert) ✓ TC15 Med/Hvy Truck: Suspension/Steering Systems @else ○ TC15 Med/Hvy Truck: Suspension/Steering Systems @endif {{ $registration->tc15_recert ? 'X' : '-' }}
@if($registration->ac5_cert) ✓ AC5 Auto: Heating & Air Conditioning @else ○ AC5 Auto: Heating & Air Conditioning @endif {{ $registration->ac5_recert ? 'X' : '-' }} @if($registration->tc16_cert) ✓ TC16 Med/Hvy Truck: Elec./Electronic Systems @else ○ TC16 Med/Hvy Truck: Elec./Electronic Systems @endif {{ $registration->tc16_recert ? 'X' : '-' }}
@if($registration->ac6_cert) ✓ AC6 Auto: Electrical/Electronic Systems @else ○ AC6 Auto: Electrical/Electronic Systems @endif {{ $registration->ac6_recert ? 'X' : '-' }} @if($registration->bc9_cert) ✓ BC9 Collision: Non-structural Analysis @else ○ BC9 Collision: Non-structural Analysis @endif {{ $registration->bc9_recert ? 'X' : '-' }}
@if($registration->ac7_cert) ✓ AC7 Auto: Automatic Trans/Trans Axle @else ○ AC7 Auto: Automatic Trans/Trans Axle @endif {{ $registration->ac7_recert ? 'X' : '-' }} @if($registration->bc10_cert) ✓ BC10 Collision: Painting/Refinishes @else ○ BC10 Collision: Painting/Refinishes @endif {{ $registration->bc10_recert ? 'X' : '-' }}
@if($registration->ac8_cert) ✓ AC8 Auto: Manual Drive Trains & Axles @else ○ AC8 Auto: Manual Drive Trains & Axles @endif {{ $registration->ac8_recert ? 'X' : '-' }} @if($registration->bc11_cert) ✓ BC11 Collision: Structural Analysis @else ○ BC11 Collision: Structural Analysis @endif {{ $registration->bc11_recert ? 'X' : '-' }}
Payment Information
Fee Paid By {{ $registration->fee_paid_by ? ucfirst($registration->fee_paid_by) : 'N/A' }} Number of Exams {{ $registration->number_of_exams ?? '0' }}
Total Fee ${{ $registration->total_fee ?? '0' }}
Credit Card Number {{ $registration->credit_card_number ? 'XXXX-XXXX-XXXX-' . substr($registration->credit_card_number, -4) : 'N/A' }} Expiration Date {{ $registration->expiration_date ?? 'N/A' }}
Name on Card {{ $registration->name_on_card ?? 'N/A' }} CVV {{ $registration->cvv ? 'XXX' : 'N/A' }}
Billing Address {{ $registration->billing_address ?? 'N/A' }}
Cardholder Signature {{ $registration->cardholder_signature ? 'Signed' : 'N/A' }}

Payment Instructions: If paying by credit card, you may fax your form to (305) 362-3134. Please remember to sign above. Thank you. Do not send cash. Credit Card, Debit Card, Company Cheks ONLY or money order for the total fee, made payable to AATI. Mail to: 6801 West 20th Avenue, Hialeah, FL 33014.

Signature Acceptance by applicant

By signing below, I am accepting the policies and procedures described on the back of this registration form.

Signature of Applicant:

@if($registration->signature) Digital Signature

{{ $registration->first_name }} {{ $registration->last_name }}

Signed on: {{ $registration->signature_date ? $registration->signature_date->format('F j, Y, g:i A') : 'N/A' }}

@else

No signature provided

@endif
Policies Acceptance
Read Policies & Procedures {{ $registration->accept_policies ? 'Accepted' : 'Not Accepted' }}

Visit our website at: www.aati.edu * Telephone: 305-362-5519 * E-mail: admission@aati.edu