advance placement – lpn/lvn application packet checklist

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 application. Packet materials are available from a Nursing Program Advisor.
PLEASE PRINT OR TYPE
Completed applications 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