6wk-- Return to Practice COURSE ENROLLMENT

I, First Name *Last Name *   (malefemale) with DOB   MM/DD/YEAR*, would like to register to  start enrollment in the    Please Select 6wk Return to Practice *    Total Cost:     Please Select $1000 *     Requested Course start date:   Date*   

   Address Line *   City*   State*   Zip*   Area Code*   Phone Number *   
Email *   Social Security # (last 4)   SS#*   

What college did you receive your Nursing degree?   Name of school *What year?    Date of Graduation *   
What state were you last licensed as a RN and what year did license lapse? number of times, Dates???* 
Have you taken a RN Remediation course in the past?   Yes   No*   
Do you currently work in Healthcare setting?    Yes    No*   
If yes, what is your current role in healthcare?   Job-Title         
What do you consider your areas of weakness?   Type yours response *   
What do you consider your areas of strengths?   Type your response *