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Full Legal Name
Mailing Address (street or P.O. Box)
City
State
ZipCode
Country of Citizenship
Date of Birth
Social Security Number
NIB Number
Daytime Telephone
Email Address
Gender
Female
Male
Other
Prefer not to answer
Name of High School
City
State
Year of Graduation from high school
Postsecondary Credentials & Certifications
The following questions are for the purpose of government statistics and will not otherwise be shared:
Disability Status (Select One)
None
Yes
Disability Affecting Employment
Developmental Disability
Learning Disability
Prefer Not to Answer
Ethnicity (Select One)
Hispanic
Non- Hispanic
Race (Select all that apply.)
White/Caucasian
Asian
Hawaiian or Pacific Island
Black/African American
American Indian or Alaskan Native
Prefer Not to Answer
Have you been convicted of a misdemeanor or a felony? List the year and describe the event:
Summarize previous work experience:
List qualities you have which will help you be a competent, compassionate Certified Nursing Assistant:
Share relevant life experiences and explain why you enrolled for this training:
REQUIREMENTS OF APPLICANT
• Submit the following medical records with this application:
o TB test and results, within past year
o Vaccination (Diphtheria/Tetanus/Pertussis) within past 10 years
• Student must be 16 years of age by start of training
• Student must be able to lift 40 – 60 pounds
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