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General Information

Name*

First Last

Date of Birth*

Social Security #*

Sex*

Marital Status*

Highest Level of Education Completed*

Race/Ethnic Origin

Nationality*

Residency Status*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Contact Phone*

Cell Phone*

Email*

Emergency Contact Information

Contact Name*

First Last

Relationship*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Contact Phone (Home)*

Cell Phone*

School Information

Program Interested*

Schedule Interested*

How did you hear about us?*

Have you applied to First Career Center before?*

Yes
No

If Yes, when?

Education Information

High School*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Study Period*

Did you graduate?*

Yes
No

If Yes, degree

College

College Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Study Period

Did you graduate?

Yes
No

If Yes, degree

Other, if any

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Study Period

Did you graduate?

Yes
No

If Yes, degree

Reference Information (Please List 3 professional references)

First Reference Name*

First Last

Relationship*

Email*

Phone*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Second Reference Name*

First Last

Relationship*

Email*

Phone*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Third Reference Name*

First Last

Relationship*

Email*

Phone*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

First Career Center Sworn Disclosure

Have you ever been convicted of a law violation(s) but exclude offenses committed before your 18th birthday, which were finally adjudicated in a juvenile court under the youth offender law?*

Yes
No

If Yes, please explain

Are you subject to any pending criminal charges?*

Yes
No

Age Certification*

By checking this box I acknowledge and warrant that I am at least 18 years of age. Certify the information

Certify the information*

By checking this box I certify that the information I have provided are true and complete to the best of my knowledge and understand that all information provided will be used by First Career Center to determine my qualification for admission. I understand that any false, misleading or incomplete answer statement or implication made by me in connection with this application or the application process, or any failure to disclose any relevant information, shall result in the denial and /or revocation of admission to First Career Center including dismissal from First Career Center if matriculated and may also lead to future denial and or revocation of licensure as a Practical Nurse, Nursing Assistant or Medication Aide. I hereby give First Career Center permission to investigate my personal, Criminal, educational and employment background and history and to contact persons, organizations, institutions or government agencies who may have knowledge of me. In Consideration for First Career Center reviewing my application for admission, and intending to be legally bound, I hereby release First Career Center subsidiaries, affiliates, trustees, officers, employees and agents(collectively hereinafter referred to as First Career Center), from any and all claims or liability, known or unknown, arising from First Career Center investigating my background and all persons, organizations, institutions or government agencies supplies such information. Finally, it is my understanding that I shall not be considered for admission to First Career Center until I have submitted all credentials and otherwise satisfied all requirements for a timely and complete application for admission. I further understand that an application which satisfies all application requirements is not guaranteed admission into First Career Center Nursing Program. I agree to inform First Career Center of any changes in the information I have provided on this application otherwise in connection with application process. If First Career Center offers me admission, and I decide to matriculate, I agree to comply with any and all of First Career Center Policies, rules and regulations, as amended from time to time First Career Center does not discriminate on the basis of age, race, religion, gender, sexual orientation, national origin, disability or veteran status in its program and activities. I also understand that First Career Center School reserves the right to cancel a class when deemed necessary either before the class begins or in an ongoing class.

APPLICATION FORM

General Information

Emergency Contact Information

School Information

Education Information

Reference Information (Please List 3 professional references)

First Career Center Sworn Disclosure