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PERSONAL INFORMATION

Class Desired**

August 2023
February 2024

First Name*

Complete Middle Name*

Last Name*

Maiden Name

Mailing Address*

Street Address City State ZIP Code

Physical Address*

Street Address City State ZIP Code

Phone*

Email*

Please Confirm Email*

Date of birth*

Social Security Number**

Please Confirm Social Security Number*

Are you a U.S. citizen?**

Yes I am a U.S. Citizen
No but I am an eligible non-citizen
No I am not a citizen or eligible non-citizen

Mother's Maiden Name*

EMERGENCY CONTACT

Name

First Last

Phone

Relation

Address

Street Address City State ZIP Code

Did You Graduate from a State Recognized High School or Obtain a GED?*

EDUCATION

Name of High School*

Date graduated or obtained GED*

College

Dates attended college

Gender

Ethnicity

Marital Status

How did you hear about us?

EMPLOYMENT INFORMATION

Present employer

Position

Dates of employment

Previous Employment

Please write a short statement of why you want to be a practical nurse.*

Have you ever been convicted of any criminal offense in any state or in federal court (other than for minor traffic violations?*

Yes
No

If yes, please contact the Admissions Specialist.

I understand that false statments or omission on any part of the application may be considered sufficient cause for denial of admission or dismissal from the program.*

Yes, I understand.

Have you lived in any other state besides your current state of residence within the passed five years?*

Yes
No

If you answered yes to the previous question, please list all out of state addresses within the passed five years below.*

Apply Online Form

By checking the box below, you acknowledge and agree that the Capital Area School of Practical Nursing Application Fee of $75.00 is non-refundable. No application will be reviewed without payment. You acknowledge and agree to not submit registration for pre-entrance exam until Application Fee has been received.

I agree to the statement above regarding my payment

(217) 585-1215

info@caspn.edu

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