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APPLICATION FOR LPN ADMISSION

APPLICANT INFORMATION

LEGAL NAME (Enter name exactly as it appears on legal documents (driver’s license, green card, passport, etc.)

Legal Last Name *

Legal First Name *

Legal Middle/Maiden Name

PREFERRED NAME

Preferred Last Name

Preferred First Name

Preferred Middle/Maiden Name

Social Sequrity Number *

 

Date of Birth *

 

Gender *


Status *


Address *

Apartment / Unit #

 

City *

State/Province *

Zip/Postal Code *

E-mail Address *

Primary Phone *

Secondary Phone *

Ethnicity



EDUCATION INFORMATION

Please check the highest level of education completed *

RESIDENCY

How long have you been an Illinois resident? *

Year(s) Month(s) County:

CITIZENSHIP

    
ALIEN RESIDENT NUMBER:
Note: Permanent residents must submit a copy of both sides of their Alien Registration Receipt Card.
 

MILITARY SERVICE

Have you completed at least one year of active duty in the U.S military?
Dates: (from) Month Year (to) Month Year
Veteran File No.
If male, aged 16-26, have you registered with the selective service?
 

EMPLOYMENT INFORMATION

Are you currently employed? *

Employment Status *

Last Employment Date *



 
 

Current or Most Recent Employer *

Job Title

Employer Phone

Hourly Rate

Employer Website

 

Address *

Apartment / Unit #

 

City *

State/Province *

Zip/Postal Code *

 

EMERGENCY CONTACT

Last Name *

First Name

Middle/Maiden Name

Phone *

Relationship: *

WHY DID YOU CHOOSE AMBRIA COLLEGE OF NURSING?

Your answer is required to process your application form for admission.

FOR OFFICE USE ONLY



 
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Ambria College admits qualified students without discrimination on the basis of race, ethnicity, color, creed national origin, religion, sex, disability, sexual orientation, age, or family relationship to all the rights, privileges, programs, and activities accorded or made available at the institution, including but not limited to: administration or educational policies, activities, and services; financial aid programs; athletic programs; and student employment programs.

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About Ambria College of Nursing

Ambria College of Nursing is the only private nursing school in Illinois that offers a seamless ladder nursing program which consists of LPN, LPN to RN, and RN to BSN.

With classes available in the morning, evening, and weekend hours and full-time or part-time course load, our flexible schedule allows you to earn a nursing salary while pursuing your Bachelors Degree in Nursing. Read more...