2019 CNA Beck Application
To guarantee you a spot in the class, a $75.00 non-refundable deposit is required. Students are accepted on a first come first serve bases. Upon completion of this application you will be notified via E-mail the date and time of your mandatory orientation date and requirements for attending.
Please indicate which CNA class you are applying for. IE: January, March, June etc.
What is your First Name?
What is your Middle Name? If you do not have a middle name, please enter "N/A".
What is your Last Name?
What is your Maiden Name, or another name you legally went by? If you do not have one, please enter "N/A".
What is your Social Security Number? USE ONLY NUMBERS, NO DASHES (-)!
What is your date of birth?
How old are you?
Please enter your mailing street address here. DO NOT USE "ENTER" KEY, USE SPACE BAR AND COMMAS TO DISTINGUISH DIFFERENT LINES. MUST ALL BE ON ONE CONTINUOUS LINE!
Select the State you live in. If your state is not listed, please select "Other" and enter your state's name.
What is your zip code?
Please enter the county that you live in. If your county is not listed, please select "Other".
St. Clair County
What is your marital status?
What is your current living arrangement?
With Parents as a dependent
With Parents as independent
On your own
With a spouse
With a partner
Please enter your Primary Phone Number here. If your cell phone is your primary number, please enter that here. ONLY USE NUMBERS, NO (-) DASH MARKS!
Please enter your cell phone number here. If your cell is your primary number, please also enter it here. ONLY USE NUMBERS, NO (-) DASH MARKS!
Who is your cell phone carrier?
(Requested not Required) If you would prefer not to give us this information, please select "N/A".
American Indian/Alaska Native
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
This information is strictly voluntary and is to be used for statistical purposes.
Prefer not to say
Do you have a disability? This information is strictly voluntary and is to be used for statistical purposes.
Hard of Hearing
Serious Emotional Handicap
Specific Learning Disability
Have you attended Beck School of Practical Nursing before?
What high school, city, and state, did you graduate from?
What year did you graduate High School?
If you did not graduate from High School, did you receive a GED? In the box marked "other' please indicate when and where your GED was received. An official transcript in the original, sealed envelope must also be provided to the school.
Please list ALL college or vocational colleges attended as well as the years attended, beginning with the most recent first. Official transcripts required for each school listed. Failure to provide all transcripts will remove your eligibility for the program.
Are you enrolled in Beck with the intention of completing the program and receiving a Certificate?
Are you currently employed? If YES, please indicate where int he box labeled "other".
What is your Citizen status?
Foreign/International Country Citizenship
Permanent Resident (Non U.S. Citizen)
Requesting Consideration Under IL. Public Law 93-007
If you are not a U.S. Citizen, please indicate your type of Visa. If Citizen, please say "N/A".
I understand that falsification or omission of information is cause for my not being accepted or for my immediate dismissal.
I have read the information provided in this application and am familiar with its contents. By signing this form, I certify under penalty of criminal prosecution that all information on this form and any additional supporting information submitted with my application packet are true and correct to the best of my knowledge.
Send me a copy of my responses.
Never submit passwords through Google Forms.
This form was created inside of Beck Area Career Center.
Terms of Service