3445 South Blvd, Columbus, OH 43204

Admission Application

To be considered for Enrollment as a Student at Academia Medical Institute, please fill in the information below as completely and accurately as possible.

Student / Applicant Information

Applying For? *

Emergency Contact Information

Education and Academic Records

Desired Class? *

This Next section MUST be completed truthfully and honestly. Findings could preclude you from being eligible for examination for registration or Licensure in Ohio if disqualifying events are discovered. IF YES, TO ANY OF THESE QUESTIONS ABOVE QUESTIONS PLEASE PROVIDE A FULL DESCRIPTION OF THE EVENT(S) TO COMPLETE YOUR APPLICATION AND SUBMIT TO THE PROGRAM COORDINATOR AT ACADEMIA SCHOOL OF NURSING FOR REVIEW.

Have you ever been expelled or suspended from any school, college or university for any reason? *
Have you ever been convicted of either felony or misdemeanor offense? *
Have you been placed on an abuse registry? *
Do you have any physical, mental, emotional or other disabilities? *

How did you hear about us:

How did you hear about us: *