Last Name: |
First Name:
|
MI:
|
| Mailing Address:
|
City:
|
State: |
Zip Code: |
Home Phone #: |
Cell Phone #: |
Email Address: |
Date of Birth: |
| Are you a US Citizen?
Yes |
No |
GED or Highest Grade Completed? |
Social Security Number: |
| Emergency Contact |
Name:
|
Phone #:
|
Alternate Phone #:
|
| Course Information: |
| Describe what you hope to achieve from this program: |
|
Is English your second language?
No - OR -
Yes
|
Have you ever been convicted of a felony or misdemeanor?
No - OR -
Yes
|
Do you require any special accomodations because of a physical condition or disability or learning condition or disability?
No - OR -
Yes
If yes, please explain:
|
I would prefer to take:
Specific Start Date/Location
-OR-
Day Classes |
Evening Classes |
Weekend Classes |
Anytime is fine |
How did you hear about us?
Union Leader |
Employment Times |
The Telegraph |
Fosters |
The Citizen |
Internet Search |
TV |
Friend/Family (name)
or
Other (please list specific source)
|
| Certify: |
| I CERTIFY THAT ALL INFORMATION PROVIDED HEREIN IS TRUE
AND COMPLETE AND THAT I HAVE TAKEN THIS TEST BY MYSELF WITHOUT ANY ASSISTANCE.
I also certify that I have read the requirements, attendance, refund and criminal record policies.
I agree to the terms and am able to FULLY meet the requirements. I further acknowledge
that upon completion of the program if I wish to obtain a license, I must complete a NH State Police and FBI history check which includes FBI Fingerprinting. The information provided by
the applicant on this application form will be held confidential unless requested by the NH Board of Nursing. LNA
Health Careers reserves the right to deny admission to any application,
within the judgment of the Program Coordinator. Once accepted a photo
ID is required to attach to your application for our file. [Per RSA188-D:
23 "Any (student) may cancel this transaction any time prior to midnight
of the third business day after the date of this transaction".] |
| Please Check this box if you agree to these conditions. By checking this box you are electronically signing that you agree to the above terms and conditions:
|
| Date:
|
At the conclusion of this form you will be taken to our Payment
Page - your $60.00 (non-refundable) application/processing fee will be
sent to:
LNA Health Careers, 22 Concord St., 3rd Floor, Manchester, NH
03101
*Please note, the application fee is for processing your application, it does not reserve your space in class. |