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

First Name *

Last Name(Surname) *

Primary Phone *

Work Phone *

Gender *

Date of Birth * +

SSN# *

Applying For? *

Certified Nurse Aide (CNA/STNA)

Licensed Practical Nursing (LPN)

Permanent Home Address *

City *

State *

Zipcode *

Email Address *

Available Date Class? * +

Emergency Contact Information

First Name: *

Last Name: *

Telephone: *

Relationship

Education and Academic Records

High School *

City *

State *

Graduated? *

Please list any awards or honors that you have received. *

Desired Class? *

Daytime Classes

Evening Classes Evening Classes

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? *

Yes

Have you ever been convicted of either felony or misdemeanor offense? *

Yes

Have you been placed on an abuse registry? *

Yes

Do you have any physical, mental, emotional or other disabilities? *

Yes

How did you hear about us:

How did you hear about us: *

Craigslist

Facebook

Internet

Other Other

Applicant's Signature: *

Date * +

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