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.
Email address *
CNA Class *
Please indicate which CNA class you are applying for. IE: January, March, June etc.
Your answer
First *
What is your First Name?
Your answer
Middle *
What is your Middle Name? If you do not have a middle name, please enter "N/A".
Your answer
Last *
What is your Last Name?
Your answer
Maiden *
What is your Maiden Name, or another name you legally went by? If you do not have one, please enter "N/A".
Your answer
Social *
What is your Social Security Number? USE ONLY NUMBERS, NO DASHES (-)!
Your answer
Birth *
What is your date of birth?
MM
/
DD
/
YYYY
Age *
How old are you?
Your answer
Address *
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!
Your answer
City *
Your answer
State *
Select the State you live in. If your state is not listed, please select "Other" and enter your state's name.
Zip *
What is your zip code?
Your answer
County *
Please enter the county that you live in. If your county is not listed, please select "Other".
Marital *
What is your marital status?
Living Arrangement *
What is your current living arrangement?
Phone *
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!
Your answer
Cell *
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!
Your answer
Cell Carrier *
Who is your cell phone carrier?
Race *
(Requested not Required) If you would prefer not to give us this information, please select "N/A".
Gender *
This information is strictly voluntary and is to be used for statistical purposes.
Disability *
Do you have a disability? This information is strictly voluntary and is to be used for statistical purposes.
Attended Beck *
Have you attended Beck School of Practical Nursing before?
High School *
What high school, city, and state, did you graduate from?
Your answer
H.S.Year *
What year did you graduate High School?
Your answer
GED *
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.
Colleges *
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.
Your answer
Receive Certificate *
Are you enrolled in Beck with the intention of completing the program and receiving a Certificate?
Employed *
Are you currently employed? If YES, please indicate where int he box labeled "other".
Citizen *
What is your Citizen status?
Visa *
If you are not a U.S. Citizen, please indicate your type of Visa. If Citizen, please say "N/A".
Your answer
Fraud *
I understand that falsification or omission of information is cause for my not being accepted or for my immediate dismissal.
Truth *
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.
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