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GENERAL INFORMATION
*Prefix: 
*First Name: 
Middle Name: 
*Last Name: 
Maiden Name: 
*Physical Address: 
          *City:       *State:       *Zip Code: 
Mailing Address (if different): 
          City:       State:       Zip Code: 
*County: 
*Date of Birth:   /   / 
*Sex:  Male   Female
*Telephone:         Alternate Telephone: 
*Email Address:         *Social Security Number: 
PROGRAM INTEREST
Please indicate which program of study you are interested in:
Professional Nursing: Associates Degree
LPN to RN Bridge: Associates Degree
Practical Nursing: Certificate
EMT/Paramedic: Certificate    Associates Degree
EMT/Basic: Certificate
Medical Administrative Assistant: Certificate    Associates Degree
Computer Technology: Certificate    Associates Degree
Nurses Assistant: Certificate
Accounting: Certificate    Associates Degree
Administrative Assistant: Certificate    Associates Degree
Health Services: Certificate    Associates Degree
*Please indicate what year/semester you would like to enroll:    *Year:     *Semester: 
Healthcare Related Programs Only:
**Have you ever been convicted of a felony?     If Yes, when:   
    **Due to clinical components
ACADEMIC INFORMATION
(Official high school and all post-secondary transcripts or official GED transcripts will be required of all applicants)
*High School last attended: 
                                         (Name of School)                      (City)         (State)
Year graduated:      or GED received:     
Please list, in chronological order, all postsecondary institutions you have attended:
    (Use "Additional Information" section below if needed for more institutions)
 Name of Institution  City/State  Dates Attended  # hrs completed / degree earned
*Do you want any post secondary transcript evaluated for transfer of credit?
*Why have you chosen this career?  
*Plans after graduation:  
*Have you ever been enrolled at another school?
When and Where?  
EMPLOYMENT HISTORY
Please list, in chronological order, all previous work experience:
 Name of Company  City/State  Dates of Employment  Position
Please complete any additional information needed for your application - i.e. additional schools or employment history.
APPLICANT VERIFICATION
I verify that the information that I have provided is complete and correct to the best of my knowledge. I understand that any falsification or omission of facts requested could be cause for disqualification of the application process or dismissal from school. I also give permission to the school to verify any employment and reference information I provide as a part of the admission process.

This school does not discriminate on the basis of age, sex, marital status, ethnic or national background, religion, or disability when admitting students to the institution.

Yes     No
Full typed legal name (to serve as your signature):   
For verification purposes, please enter the city in which you were born:   
**Your IP address will also be captured to serve as additional verification.**