Oil City PN Application

Student Name

First NameMiddle NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

E-mail*

Campus

Mobile Number

Area CodePhone Number

Phone Number

Area CodePhone Number

Highest Grade Completed

College

High School GraduateGeneral Equivalency Diploma

Special Training

Name and City of Schools Attended

High School

College

Other School

List below beginning with most recent

Employer Name

Job Title

CityState / Province

From*

MonthDayYear

To

MonthDayYear

Employer Name

Job Title

CityState / Province

From

MonthDayYear

To

MonthDayYear

How did you hear about our program? Check all that apply.

Student or Graduate's Name that referred you to our program.

By typing my name below, I certify that the information provided is correct.*

" The State Board of Nursing shall not issue a license or certificate to an applicant who has been convicted of a felonious act prohibited by the Act of April 14, 1972 (P.L. 233, NO. 64), known as the controlled substance, drug, device and cosmetic act." Or convicted of a felony relating to a controlled substance in a court of law of the United States or any other state, territory or country unless: (1) at least ten (10) years have elapsed from the date of conviction; (2) the applicant satisfactorily demonstrates to the Board that he has made significant progress in personal rehabilitation since the conviction such that licensure of the applicant should not be expected to create a substantial risk of harm to the health and safety of patients or the public or a substantial risk of further criminal violation; and (3) the applicant otherwise satisfies the qualifications contained in or authorized by the act.

As used in this section the term "convicted" shall include a judgment, an admission of guilt or plea of nolo contendere.

Student Application

Educational Information

Employment History

All information provided will be kept in strict confidence.