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PERSONAL INFORMATION
Class Desired*
- August 2021
- February 2022
First Name*
Middle Name
Last Name*
Maiden Name
Address*
Street Address City State ZIP Code
Phone*
Email*
Date of birth*
MM
DD
YYYY
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
EMERGENCY CONTACT
Name
First Last
Phone
Relation
Address
Street Address City State ZIP Code
EDUCATION
Name of High School*
Date graduated or obtained GED*
MM
DD
YYYY
College
Dates attended college
Have you ever enrolled at CASPN or another nursing program?*
- Yes
- No
If yes, in what school?
Dates attended
Have you ever worked in a health care agency?*
- Yes
- No
If yes, in what position?
Dates employed
Agency name
OPTIONAL INFORMATION
IS IS NOT MANDATORY TO FILL OUT THIS SECTION. THE FOLLOWING QUESTIONS ARE VOLUNTARY AND ARE NOT USED IN THE SELECTION PROCESS.
Gender
- Female
- Male
- Prefer Not to Answer
Ethnicity*
If other, please specify
Social Security Number**
Place of birth
Marital Status
How did you hear about us?
Do you know someone in the program currently or a past graduate?
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.
*
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.
- I agree to the statement above regarding my payment
Application fee

In this section

Apply Online
Admission Forms
Adult CNA Courses
CPR Course Information
CPR Registration
Expenses
TEAS Testing
Apply Online
Opportunities for CASPN Students

Admissions packet

In addition to your online application, we’ll also need several other documents completed and returned to us. You may download and print the documents here.

2201 Toronto Road, Springfield, IL 62712

(217) 585-1215

info@caspn.edu

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