ONLINE VOCATIONAL NURSING PROGRAM

January 2009 Admission

Vocational Nursing North Central Texas College 1525 West California Street Gainesville TX 76240 Office 940-668-4291/Fax 940-668-6049

(Complete In Full) FULL LEGAL NAME: Last Name Any Other Last names Used: ADDRESS: Street

DATE OF APPLICATION:

First Name

Middle Name

Maiden Name

City

State

Zip Code

Home

Phone # (with area code)

Cell Phone # (with area code) Yes Yes Yes Yes Yes No No No No No No Number Number Number

E-Mail Address Year Year Year Year Year Year

HIGH SCHOOL GRADUATE: OR GED (General Education Development): Any credits from NCTC? Credits from ANY other colleges? Any RN education/classes

Have you applied for the NCTC Vocational Nursing Program before? Yes

Have you been previously enrolled in VNSG 1420 A & P for Allied Health prior to admission into the LVN Program? Yes No Semester/Year Have you been enrolled in other nursing or health related programs:

List below any licenses or health-related credentials you currently hold:

Have you ever been convicted of a crime (other than minor traffic violations)? Yes No If yes, give your age at the time, type of crime and explain disposition:

Important
By initialing below, I hereby state I am exempt from completing Declaratory Orders of Eligibility for Licensure through the Texas Board of Nursing.

*North Central Texas College does not discriminate on the basis of race, color, national origin, gender, religion, age or disability in employment or the provision of service.

ONLINE VOCATIONAL NURSING

January 2009 Admission

Statistical Survey
Vocational Nursing - North Central Texas College 1525 West California Street Gainesville TX 76240 940-668-4291

Name Date of Birth Social Security Number

Date

Gender: Male Female

Ethnic Origin: White, Non-Hispanic Black, Non-Hispanic Hispanic Asian/Pacific Islander American Indian/Alaskan Native International Student

Educational Background: GED High School Diploma Other Medical Certifications Specify: College Degree Earned Specify: Any RN Education/Classes How Many Hours

What school did you attend?

Other: Have you ever been enrolled in a remedial/developmental class? Are you receiving any financial aid? Specify Do you have a disability that requires any special accommodations? Specify Is English the language spoken in the home? Are you a single parent with primary responsibility for child care? Are you a former homemaker returning for training?

Y Y Y Y Y Y

N N N N N N

Important
By initialing below, I hereby state I have read all sections of the Advisement Session and followed directions for completion of the VN Department application and NET testing processes.

*North Central Texas College does not discriminate on the basis of race, color, national origin, gender, religion, age or disability in employment or the provision of service.