Form Test | Mid-Del Technology Center

Practical Nursing Application

Application for entry consideration for the Practical Nursing program.

"*" indicates required fields

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:

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: kdunn@mid-del.net

Questions, Comments, and Suggestions

"*" indicates required fields

Name*

First Last

Email*

Phone

Course Type

Full-Time Programs

Adult Short-Term Classes

Workforce Development

Message*

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