Application Form:
Post Graduate Emergency and Trauma Nursing Diploma Program, and NCLEX Review Course
Email address *
What program or course are you applying for? *
What is your legal last name? *
Your answer
What are your legal given names? *
Your answer
Former last name (if applicable)?
Your answer
Address where you live? *
Your answer
Please provide your most recent Nursing License Information: License Type (e.g. RN, BSN, NEMT) *
Your answer
License Number *
Your answer
State of Licensure *
Your answer
What is the best email address to reach you at? *
Your answer
What is your cell phone number? *
Your answer
Do you have a backup phone number to your cell? If yes - please provide. *
Your answer
What languages do you speak (No reflection on your application - just helps with placement) *
Your answer
Have you served in the military? If yes - what is your current military status? *
Your answer
Are you an American citizen? If no, what is your current status in the USA? (e.g. Permanent Resident, Resident Alien, Visa type, etc.) *
Your answer
Have you ever been convicted of a felony? *
Have you ever been convicted of a non-felony? *
Emergency Contacts: Full Name(s), relationship to you, Phone numbers. Please provide at least two if possible. *
Your answer
Employment History for past 5 years: For each job, list (1) Name of Business (2) Title of your position (3) a BRIEF outline of your responsibilities (4) Name of Supervisor (5) Months/years in this position (6) how to contact, and if you give us permission to contact them. NOTE: If you have not been working, just state so below. MOST RECENT JOB: *
Your answer
SECOND MOST RECENT JOB: *
Your answer
THIRD MOST RECENT JOB: If more - please submit an email listing employment history to liz@uhtc.org
Your answer
Education History: Highest Degree Attained; Date Completed; and Institution *
Your answer
Education History Continued: Additional Degrees, dates completed and Institutions.
Your answer
How did you hear about us? (If the answer is from a "friend or colleague", was this person a previous student of Dr. Thomas?) (If answer is a conference or event, please provide name of the event or other additional information). Thank you!
Your answer
Is there anything else you would like us to know?
Your answer
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This form was created inside of United Heart Training Center.