New Online LPN Application

Universal Training Institute

174 Jefferson Street, Perth Amboy, NJ 08861

Online LPN Application

LPN APPLICATION FORM

Complete the full application below to apply for the LPN program.

PERSONAL DATA – PART I

Social Security No

First Name

Last Name

Middle Name

Maiden Name

Home Phone
Cell Phone
Alternative Phone

Street
Address Line 2

City
State/Province
Zip/Postcode
Country
Email

PERSONAL DATA – PART II
This section is for statistical purposes only, acceptance is granted with no regard to race or national origin. Please check all that may apply
Gender
Birth Date
Marital Status

Maiden Name if Married:

Spouse Last Name

Spouse First Name:

Spouse Middle Name

If other specify:

Single Parenthood

If Yes, specify number of children:

Citizenship:

Country if Citizenship

Country of Birth

Veteran/ Active Serviceman
Yes No Not Selected

Ethnicity

PERSONAL DATA – PART III
Have you ever been convicted of a criminal or military offense, excluding minor traffic violations?

If yes, please provide a detailed explanation below

Have you ever been academically dismissed from, declared ineligible to attend or incurred action at any previous institution?

If yes, please provide a detailed explanation below

If you answered “Yes” to any of the above questions, you may be required to attend a personal interview with an Administrative Representative for further evaluation.

How did you hear about Universal Training Institute? (Check all that may apply)

If Newspaper, which one?

Social Media, which one?

EMPLOYMENT DATA (if not employed, please type/ print “NOT EMPLOYED”)
Employment History: Please list most recent employers in the last three years. Start with the most recent or current. Dates must reflect month and years (For example: Start Date 12/11- End Date 01/13).
Employer

City/State

Name of Supervisor

Phone

Dates

Reason for Leaving

Position Held

EDUCATIONAL DATA - PART I
HIGH SCHOOL INFORMATION:
Name of High School

City/State

Zip Code

Country

Date of Graduation:

Grade Point Average (GPA)

EDUCATIONAL DATA - PART II
POST-SECONDARY EDUCATION
Have you attended any other schools after receiving your High School Diploma or GED
Yes
No

If yes, please complete the information below

Name of Institution

City/State

Country (If outside of US)

Dates Attended

Credits Earned

GPA

Degree/Certificate Earned

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Name of Institution

City/State

Country (If outside of US)

Dates Attended

Credits Earned

GPA

Degree/Certificate Earned

REFERENCES: Please list two references; please EXCLUDE all relatives; spouses, and children.
Last Name:

First Name:

Phone-Relationship

Yrs known

---

Last Name:

First Name:

Phone-Relationship

Yrs known

Required Documents
Original documents will need to be presented during the time of admission.
Identification (driver's license, birth certificate or passport)

High School Diploma or G.E.D. certificate

Proof of Legal Status

Birth Certificate or Valid Passport, Permanent Resident Card, Replacement of Permanent Resident Card, Alien Registration, Certificate of US Citizenship or Naturalization, or Form I-797 Request for Renewal

Criminal Background Check

Current CPR Card

Physical Assessment Report

Approved Loan Document/Payment Schedule Agreement

APPLICANT AGREEMENT
I certify that the information given in the Registration Form is true and correct to the best of my knowledge. I recognized that with holding or his representing information may result in cancellation of my acceptance.
Signature

Date

DO NOT WRITE IN THIS BOX: OFFICE USE ONLY
Date of Test

TEAS Test Score 1:

Return Date

1.Date of Test

TEAS Test Score 2:

Admission Director

Enter the above code

Required