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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:

	RN-Bridge Nursing:
	Practical Nursing:
	EMT/Paramedic:
	EMT/Basic:
	Medical Administrative Assistant:
	Data Processing Technology:
	Accounting:
	Administrative Assistant:

*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.**