Apply Licensed Practical Nurse(LPN)

Personal Information

First Name *
Middle Name
Last Name *
Date Of Birth *
Social Security Number *
Driver's License/State ID *
Cell Phone *
Home Phone *
May we call, text and, or send you automated messages to your Cell Phone? *
YesNo
Email Address *

Present Address

Address *
Address 2
City *
State *

Permanent Address(if different than present address)

Address
City
State
Zip Code

Emergency Contact

First Name *
Middle Name *
Last Name *
Email Address *
Cell Phone *
Home Phone *
Relationship *
First Name *
Middle Name *
Last Name *
Email Address *
Cell Phone *
Home Phone *
Relationship *
First Name *
Last Name *
Last Name *
Email Address *
Cell Phone *
Home Phone *
Relationship *

Disability

Do you have any disability that you want us to be aware of? *
YesNo
If you answered YES, please explain what kind of disability you have

PLEASE SELECT THE COURSE THAT YOU ARE APPLYING: *
Pre-Nursing Nursing ProgramPractical Nursing Educational program.
If you selected Pre-Nursing Program(please select the courses below)
Medical TerminologyHuman Anatomy and Physiology IHuman Anatomy and Physiology IIPharmacology Nursing
When do you want to start your classes? Please write the Month and the Year: *

PRACTICAL NURSING PROGRAM SCHEDULE

The applicant must initial both the classroom/Skills Lab and Clinicals boxes. By putting my initials in the boxed indicates that I understand I am required to attend the classroom, Skills Lab and Clinicals as scheduled.
Classroom/Skills Lab: *Monday to Friday 8:00 am-2:30 pm (A few times Skills are scheduled for 8 hours)
Clinicals *Morning: 06:30am-03:00pm or Afternoon 01:30pm-10:00pm. (Clinicals are scheduled during the weekday. However, students may be required to attend clinicals on weekends)
Instructions START MONTH START WEEK SCHOOL DAYS CLASS SCHEDULE TIME LUNCH BREAK DAILY CLOCK HOURS DAILY CLINICAL HOURS(8HRS) LENGTH IN MONTHS January First Monday of the first week Monday to Friday 08:00am to 03:00pm 12:00pm to 12:30pm 6.5 06:30am- 03:00pm or 01:30pm- 10:00pm 12 months January to December May First Monday of the first week Monday to Friday 08:00am to 03:00pm 12:00pm to 12:30pm 6.5 06:30am- 03:00pm or 01:30pm- 10:00pm 12 months May to April September First Monday of the first week Monday to Friday 08:00am to 03:00pm 12:00pm to 12:30pm 6.5 06:30am- 03:00pm or 01:30pm- 10:00pm 12 months September to August
When do you want to start your classes? Please write the Month and the Year: *
Program Start Date: MM/DD/YYYY. *(Please check the school course schedule on the school website)
Tell us briefly why you are choosing your program of study?

US MILITARY RECORD

Branch
Date Entered
Date Discharged
Type of Discharge

Current Employment

Employer's Name *
Telephone Number *
Address *
City *
State *
Zip Code *
Position Held *
Supervisor *
Date Employed-Started On(month/year) *
Employed To(month/year) *
Salary($)

Educational Background

List all educational schools attended with degrees, diplomas, or certificates received.
Name *
Type of Studies *
Dates Attended *
Name
Type of Studies
Dates Attended
Name
Type of Studies
Dates Attended
Name
Type of Studies
Dates Attended

References

Name *
Address *
Telephone Number *
Name *
Address *
Telephone Number *
Name *
Address *
Telephone Number *

CITIZENSHIP

Place of Birth City *
State/Province *
Country *
US Citizen *
YesNo
Country of Citizenship *
Permanent Resident *
YesNo
Alien Number
Other Visas
I-94
NOTE MedNoc Training College does not issue I-20 for international students.

BACKGROUND INFORMATION

If you answer YES to any of the questions below, explain by writing in the space provided below after the questions A through D. The explanation for a YES answer should include, but not be limited to: 1) State and/or jurisdiction. 2) Nature of complaint/offense. 3) Disposition of complaint and/or offense (e.g., “dismissed insufficient evidence,” “deferredsentence”). 4) Date of disposition. 5) Attach a copy of any correspondence received by you, the applicant, regarding the complaint/offense.
Have you ever: *
1) participated in a first offender program; 2) deferred adjudication or other program or arrangement where adjudication has been withheld; 3) plead guilty or no contest; 4) been convicted; 5) received a deferred sentence; and/or 6) been sentenced for any criminal offense in any state or US jurisdiction regardless of whether this matter has been expunged or otherwise removed?YesNo
Have you ever been found in violation of any state, US jurisdiction, or federal law regulating the Practice of a health care profession? *
YesNo
Are any disciplinary actions or allegations, pending or substantiated, against you or your Certification or health care professional license in any state or US jurisdiction? *
YesNo
*
Have you had any certificate, license, registration, or other privilege to practice in t h e health care profession denied, revoked, suspended, restricted, reprimanded, censured, or placed on probation by a state or US jurisdiction, federal or foreign authority, or have you ever surrendered such credential to avoid, or in connection with, action by such authority?YesNo
If YES Explain

Verification

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Call Today: (405) 225-7876|Email: info@mednoc.com

Personal Information

Present Address

Permanent Address(if different than present address)

Emergency Contact

Ethnicity

Disability

ATTESTATION

PRACTICAL NURSING PROGRAM SCHEDULE

STUDENT VERIFICATION

US MILITARY RECORD

Current Employment

Educational Background

References

CITIZENSHIP

BACKGROUND INFORMATION

APPLICANT’S CERTIFICATION AND AGREEMENT

President:Mr. Paul Mungiria, MSN, BSN, RN, CCRN.

Phone: 405-225-7876 Ext 101.

Fax: 405-421-9521

Email: paulmungiria@mednoc.com

Verification