advance placement â lpn/lvn application packet checklist

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Advance Placement Applicant PRIOR TO BEING ACCEPTED TO THE PROGRAM: Complete a panel interview with the Admission, Progression, and Graduation Committee. A Nursing Program Advisor will schedule the interview. IF YOU ARE NOTIFIED OF ACCEPTANCE TO THE PROGRAM: Submit on the day of semester nursing program orientation: Completed Health Data / Physical Exam form– details provided with acceptance letter Immunizations and Tests Required by State Law / Clinical Facilities form Copy of current CPR card – American Heart Association only Updated 2/1/11
Advance Placement Applicant Application for admission to Application for admission to: ASSOCIATE DEGREE NURSING PROGRAM Dona Ana Community College does not discriminate on the basis of race, color, creed, national origin, religion, age, gender, sexual orientation, political affiliation, or physical disability. ADVANCED PLACEMENT – LPN/LVN APPLICATION FALL 2011 The New Mexico Department of Health Caregivers Criminal History Screen Application must be submitted with your ADN Program <strong>application</strong>. Packet materials are available from a Nursing Program Advisor. PLEASE PRINT OR TYPE Completed <strong>application</strong>s are due no later than May 2, 2011. Name in Full: Home Address: Last First Middle Number & Street County City State Zip _______ Home Phone: Alternate Phone: _____ Social Security No.: __ __ __ - __ __ - __ __ __ __ NMSU E-mail Address: _________________@nmsu.edu Residency: State of Legal Residence: ______________ NMSU Banner Number: ______________________ Date of Birth: ______________________________ If a resident of NM, County of Legal Residence: __________________ LPN License #:_________________________ State: ___________ Expires: ________________ __________________________________ _________________________ _________________ _____________________ LPN Nursing School Attended Location (City, State) FROM (mo. & year) TO (mo. & year) Reason for leaving: ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ Please initial one of the following: ____________ YES, DACC may contact the above listed nursing program(s) ____________ NO, DACC may NOT contact the above listed nursing program(s) Provide information concerning high school(s) attended or G.E.D.: Name of School City & State Dates Attended Provide information concerning all college, university, vocational schools and/or allied health schools attended. List all vocational programs and certifications, including military, which relate to health care. Use additional pages if necessary. Academic regulations require that students who have registered at other colleges or universities may not disregard their records at such institutions when Updated 2/1/11
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advance placement â lpn/lvn application packet checklist