Practical Nursing Application

Date*
Name*
First Middle Last
Address*
Street Address Address Line 2 City State ZIP Code
Permanent Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*
Educational Information: High School name & location of last high school attended: (Must submit copy of transcript)*
Name of high school City State Year graduated from high school or last year in school
General Educational Development (GED) Information: (Must submit copy of score & certificate)*
Score: Date Taken: Testing Location:
Select highest grade completed in school:*
Applicants graduating from a high school outside the United States must complete the GED test.
List other schools attended: (Include career tech, colleges, universities, etc.*
School Name School City School State
Health Care Experience: Describe any health care or health occupations experience, such as certifications obtained, such as certified nurse assistant, unit clerk, etc. Include volunteer experience. Please attach copies of health occupations certifications obtained.*
Record of Employment:*
Name of Employer Address or Phone Number Dates of Employment (List most recent first) May we contact
Applicants may submit up to 3 reference letters from employers and/or past professors/teachers. Applicants will receive points for each letter submitted.
Have you ever been arrested?*
If yes, please provide an explanation:
Have you ever been convicted of a misdemeanor or a felony?*
If yes, please provide an explanation:
APPLICATION CHECKLIST:

_____ Application completed . Incomplete applications will not be considered.

_____ High school transcript or GED scores attached; TOEFL test scores if required.

_____ Prerequisite transcript(s) attached.

_____OSBI Background Check - Original copy attached.

_____ Test scores attached (TABE, Accuplacer or ACT).

_____ Reference Letters (up to 3)

_____ Copy of health occupations certificate(s) attached - optional.
MID-DEL SCHOOL DISTRICT STATEMENT OF NONDISCRIMINATION

The Mid-Del Public School District No. I052 does not discriminate on the basis of race, color, national origin, sex, pregnancy, gender, gender expression or identity, religion, veteran status, sexual orientation, disability, age, or genetic information in its programs and activities and provides equal access to the Boy Scouts and other designated youth groups. The following person has been designated to handle inquiries regarding the non-discrimination policies: Mid-Del Schools Assistant Superintendent of Teaching & Learning Address: 7217 SE 15th 15th Street, Midwest City, OK 73110 Phone: 405.737.4461 x1225 Email: [email protected]

Name of high school	City	State	Year graduated from high school or last year in school

Name of Employer	Address or Phone Number	Dates of Employment (List most recent first)	May we contact

Score:	Date Taken:	Testing Location:

School Name	School City	School State