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Applicant Status
New Student
Applying for Readmission
Program I am applying for
Practical Nursing Program (diploma)
Registered Nursing Program (diploma)
$50 non refundable application fee enclosed? *fee applicable to New Students only
Yes
No
Name
Gender
Male
Female
Date of birth
Email Address
Home Address
Home Phone
Cellphone
Does your employer assist with tuition costs?
Yes
No
Work Address
Ethnicity (optional; this information will not be used in a discriminatory manner)
Black or African American
White
Asian
Hispanic
Native American
Two or more races
Unknown
Are you a US citizen?
Yes
No
Have you served in the US military?
Yes
No
Have you ever pled guilty or been convicted of a felony?
Yes
No
(If yes, please explain)
Name and Address of High School
Date Craduated/GED Completed
Name and Address of College/other
Dates Attended
Hours Completed
Name and Address of College/other
Dates Attended
Hours Completed
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