LNA Student Application / Pre-Test

Questions please call  -  603-647-2174
LNA Application off-linePrefer to Print, FAX or Mail your application, click here?
student
First Name MI
Last Name
Mailing Address
Apt./Suite Number
City
State
Zip Code
Home Phone
Cell Phone
Social Security #
Email
Birth Date (mm/dd/yyyy)
Are you a US Citizen ?   Yes: No:
Is English your primary language?   Yes No
Do you have a High School Diploma?   Yes No
Last Grade Completed ?
Have you EVER been convicted of a Violation, Misdemeanor or Felony ? :    Yes: No:

*Please note, Criminal Record checks are conducted on all of our students. Falsifying information on this application can result in termination from the program.

 

Emergency Contact Name
Emergency Contact Phone
Do you have a documented disability that you would like us to be made aware of?   Yes: No
If yes, please explain:
Describe what you hope to achieve from this program:
How did you hear about us ?         

I would prefer to take a :        
Start Date:
Enter preferred location of training:

I CERTIFY THAT ALL INFORMATION PROVIDED HEREIN IS TRUE AND COMPLETE AND THAT I WILL BE TAKING THE FOLLOWING PRE-TEST BY MYSELF WITHOUT ANY ASSISTANCE. I agree to the terms and am able to FULLY meet the requirements. I further acknowledge that upon completion of the program if I wish to obtain a license, I must complete a NH State Police and FBI history check which includes FBI Fingerprinting.   The information provided by the applicant on this application form will be held confidential unless requested by the NH Board of Nursing. LNA Health Careers reserves the right to deny admission to any application, within the judgment of the Program Coordinator. Once accepted a photo ID is required to attach to your application for our file. LNAHC reserves the right to require further English comprehension testing prior to admission into the program. [Per RSA188-D:23 "Any (student) may cancel this transaction any time prior to midnight of the third business day after the date of this transaction".]

 Please check this box if you agree to the preceding terms and conditions. By checking this box you are electronically signing that you have read and understand the refund, attendance & criminal record policies, that you can meet the essential requirements and that you agree to all said terms and conditions.