Practical Nursing Application

First Name:

Middle Name:

Last Name:

E-mail Address:

Phone:

Last four numbers of your Social Security Number:

Student ID:

NOTE: This number is obtained by applying to UA-PTC and being accepted by the institution.

Address:

City:

State:

Zip code:

Highest level of education completed:

Have you ever been convicted of a felony?

Yes

No

If "Yes", you have been convicted of a felony, please explain the circumstances around the conviction:

Have you ever had a professional license or certification on probation, suspended, revoked or have any other type of administrative action on a healthcare license, certification or any other professional license or certification in any other professional field?

Yes

No

If you answered yes to the previous question, please explain the circumstances around it:

How did you hear about our Practical Nursing program? (check all that apply)

UA-PTC Website

Counselor

Recruiting Event/Job Fair

Radio, Billboard or TV ad

Social Media

Other...

Have you previously attended one of our Nursing programs (CNA, CMA, or Practical Nursing)? If so, when?

If you previously attended one of our Nursing programs (CNA, CMA, or Practical Nursing) at UA-PTC did you successfully complete the course?

If you previously attended one of our Nursing programs (CNA, CMA, or Practical) but did not obtain certification/licensure? Describe the reason and/or why you left prior to obtaining certification/licensure?

Have you previously attended a Nursing Program (PN OR RN) at any other location? If so, please describe all dates of attendance, when and why you left? **Please note that a letter of good standing is required from each program listed.

Are you at least 18 years of age?

Yes

No

Do you have a high school diploma or GED?

Yes

No

Do you hold a current healthcare related certification or license?

Yes

No

Please provide a description for any certification or license held:

Do you hold a current American Heart BLS Healthcare Provider license?

Yes

No

Lapsed

Certification of Information:

I certify that the information provided in this application is true and complete and understand that intentional false statements could lead to program dismissal as a student or rejection as an applicant.