APPLICATION FOR ADMISSION
NURSING ASSISTANT PROGRAM
Phone 881-5940

T R E A S U R E V A L L E Y C O M M U N I T Y C O L L E G E
O N T A R I O, O R E G O N 97914
650 COLLEGE BLVD
ONTARIO, OR 97914
_____________________________________________________________________________________


PLEASE TYPE OR PRINT

SOCIAL SECURITY NUMBER_________________________

CLASS DATE ATTENDING_______________________________


NAME___________________________________________________________________________


PLEASE STATE ANY NAME BY WHICH YOU MAY HAVE BEEN IDENTIFIED IN ANY RELEVANT ACADEMIC OR EMPLOYMENT RECORDS

_________________________________________________________


PRESENT ADDRESS_____________________________________________________________________________________

STATE____________ ZIP____________

PHONE (Home)______________________ (Cell)_______________________

PERMANENT ADDRESS_________________________________________________________

CITY___________________________ STATE________ZIP___________________


DATE OF BIRTH_____________________ AGE_________ SEX Female Male

US CITIZEN Yes NO
VETERAN Yes No


IN CASE OF EMERGENCY NOTIFY

NAME__________________________________________________ PHONE_____________________________


NAME and LOCATION OF SCHOOLS ATTENDED

YEAR GRADUATED

HIGH SCHOOL

GED

ADULT DIPLOMA

COLLEGE


MAIL OR HAND DELIVER THIS COMPLETED APPLICATION (that includes HS diploma, GED, or Reading Scores) TO THE NURSING DEPARTMENT

THE STATEMENTS IN THIS APPLICATION ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE.


DATE______________________ SIGNATURE OF APPLICANT_______________________________________________



3/09