APPLY ONLINE – Victory College Of Nursing

Name
First Middle Last
Email
SSN
Gender
- Male
- Female
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Date Of Birth
MM
DD
YYYY
Program
Starting
EDUCATIONAL RECORD:
- I certify that I have a standard high school diploma or GED diploma as listed below.
High School
City
State
Graduation Date
MM
DD
YYYY
GED Place Taken
City
State
GED Date Taken
MM
DD
YYYY
Do you have a copy of your high school diploma or GED?
- Yes
- No
Schools and Colleges Attended Since High School:
Institution
City
State
Grad Year
PERSONAL INFORMATION
Marital status
No. of Dependents
Are you a U.S. Citizen?
Alien Registration #
Driver's License #
State
FAMILY INFORMATION:
Name of parent, guardian, or spouse
Phone
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
In case of emergency contact name
Phone
REFERENCES OTHER THAN FAMILY
Name
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
EMPLOYMENT RECORD
Current employer
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Work Phone
Type of work
ETHNICITY
RACE
- First Choice BY SIGNING/TYPING MY NAME BELOW, I CERTIFY I HAVE REVIEWED THE INFORMATION ABOVE WHICH IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.
Signature Student
Date
MM
DD
YYYY
Signature Parent/Guardian
Date
MM
DD
YYYY
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Schools and Colleges Attended Since High School: