Section 1 of 3 2 to go

Application for Admission

Nursing Application

CCC Student ID

Date of Birth

Legal Name

First, Middle, Last

Address

Street or Box Number, City, State, Zip

Home Phone Number

Cell Phone Number

Social Security Number

Email Address

List any other name(s) under which you have previously used:

What is your Native Language?

If English is not your native language you will have to submit an English Proficiency exam.

Person to be notified in case of emergency:

Full name, Relationship, Phone number

Admission Information:

If you have previously attended a nursing program (including LPN) please indicate the reason for leaving:

Active License

Do you currently hold an active license for one of the following:

License Number and State

Please enter your license number and state

Enrolled

Are you currently enrolled in any of the above programs? Expected graduation date:

Previous College Information

Include every college, university or vo-tech you have attended.

Entry 1

College, University, Vo-Tech

City, State, Country

Dates Attended

Degree or Certificate earned

Add another

Entry 2

College, University, Vo-Tech

City, State, Country

Dates Attended

Degree or Certificate earned

Add another

Entry 3

College, University, Vo-Tech

City, State, Country

Dates Attended

Degree or Certificate earned

Add another

Entry 4

College, University, Vo-Tech

City, State, Country

Dates Attended

Degree or Certificate earned

Add another

Entry 5

College, University, Vo-Tech

City, State, Country

Dates Attended

Degree or Certificate earned

Add another

Entry 6

College, University, Vo-Tech

City, State, Country

Dates Attended

Degree or Certificate earned

Add another

Entry 7

College, University, Vo-Tech

City, State, Country

Dates Attended

Degree or Certificate earned

Add another

Entry 8

College, University, Vo-Tech

City, State, Country

Dates Attended

Degree or Certificate earned

Add another

Entry 9

College, University, Vo-Tech

City, State, Country

Dates Attended

Degree or Certificate earned

Add another

Entry 10

College, University, Vo-Tech

City, State, Country

Dates Attended

Degree or Certificate earned

Leave an entry blank if you do not need it.

TEAS

List the date/scores of the TEAS entrance exams. Scores are good for 2 academic years: LPN minimum score 56.1; ADN minimum score 66.1.

Entry 1

Date

Score

Results to CCC Nursing

Add another

Entry 2

Date

Score

Results to CCC Nursing

Add another

Entry 3

Date

Score

Results to CCC Nursing

Add another

Entry 4

Date

Score

Results to CCC Nursing

Add another

Entry 5

Date

Score

Results to CCC Nursing

Add another

Entry 6

Date

Score

Results to CCC Nursing

Add another

Entry 7

Date

Score

Results to CCC Nursing

Add another

Entry 8

Date

Score

Results to CCC Nursing

Add another

Entry 9

Date

Score

Results to CCC Nursing

Add another

Entry 10

Date

Score

Results to CCC Nursing

Leave an entry blank if you do not need it.

Legal Qualifications Information:

Have you ever been convicted of a misdemeanor or felony? It is important that the student is aware that: The Kansas State Board of Nursing has the power to deny, revoke, limit, or suspend any license to practice nursing as a licensed practical nurse or a registered professional nurse that is issued or applied for. Please see the following information for students who may be subject to licensure denial under K.S.A. 65-1120. https://ksbn.kansas.gov/wp content/uploads/NPA/65-1120.pdf

Yes No

Signature

My signature below indicates that all of the above information is accurate to the best of my knowledge. I have read the admission requirements and legal qualifications information for licensure.

Date

Date of Signature

Your answers are saved on this device as you go. You can close this page and open the same link again to carry on.