Student Application: Visionary Health Career Training Institute LLC

CERTIFIED NURSING ASSISTANT STUDENT APPLICATION

Visionary Health Career Training Institute LLC
Please fill out the entire form below.
Certified Nursing Assistant Application
Program Applying For*
Preferred Start Date

MonthDayYear
Date
Name*

First NameMiddle NameLast Name
Preferred name (nickname):
Email Address*
example@example.com
Cell Phone Number*
Please enter a valid phone number.
Social Security Number*
XXXXXXXXX
Upload a copy of your social security card.*

Social Security Card
Cancelof
Upload a copy of your government issued photo identification. (passport, visa, state ID, state driver's license)*

Government Issued Photo ID
Cancelof
Home Address*

Street Address

Street Address Line 2

CityState

Zip Code
Have you ever applied to Visionary Health Career Training Institute?

YesNo
Have you ever been a Certified Nursing Assistant?

YesNo
Are you a citizen of the United States?*

YesNo
If no, are you authorized to work in the U.S?*

YesNo
Are you 18 years of age or older?*

YesNo
Have you ever been convicted of a felony?*

YesNo
If convicted, please explain
Education
High School Attended
High School Address
City, State
High School Start Date

MonthDayYear
Date
High School End Date

MonthDayYear
Date
Did you graduate high school?

YesNo
Do you have a high school diploma or GED?

DiplomaGED
College

If you did not attend college, leave this section blank
College Attended
College Address
City, State
College Start Date

MonthDayYear
Date
College End Date

MonthDayYear
Date
Degree type

AssociateBachelorsOther
Did you graduate college?

YesNo
Other Education
Other Education Program
Other Education Address
Other Education Start Date

MonthDayYear
Date
Other Education End Date

MonthDayYear
Date
Did you graduate from Other Education?

YesNo
Degree/Certificate of Completion Earned

YesNo
References

Someone who can speak about your personal or professional history
Reference #1

First NameLast Name
Relationship
Company
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState

Zip Code
Reference #2
Reference #2

First NameLast Name
Relationship
Company
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState

Zip Code
Reference #3
Reference #3

First NameLast Name
Relationship
Company
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState

Zip Code
Employment History

List your last 3 jobs
Employer #1
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState

Zip Code
Supervisor
Job Title
Responsibilities
Starting Salary
Ending Salary
From

MonthDayYear
Date
To

MonthDayYear
Date
Reason for Leaving
May We Contact Supervisor?

YesNo
Employer #2
Employer #2
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState

Zip Code
Supervisor
Job Title
Responsibilities
Starting Salary
Ending Salary
From

MonthDayYear
Date
To

MonthDayYear
Date
Reason for Leaving
May We Contact Supervisor?

YesNo
Employer #3
Employer #3
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState

Zip Code
Supervisor
Job Title
Responsibilities
Starting Salary
Ending Salary
From

MonthDayYear
Date
To

MonthDayYear
Date
Reason for Leaving
May We Contact Supervisor?

YesNo
Military Service
Are you a U.S. military veteran?

YesNo
Branch of Armed Forces
Rank At Discharge
Type Of Discharge
Dates Served

MonthDayYear
Start date
Dates Served

MonthDayYear
Discharge date
If Other Than Honorable, Explain
Payment Options and Authorization

Choose a class (ONLINE or IN-PERSON) and a payment option below:*

ONLINE (HYBRID) CNA TRAINING CLASS6-week or less training consists of ONLINE classroom, in-person lab skills, and clinical training in a skilled nursing facility. Financing is NOT based on your credit score. See the terms below in the FINANCING section.

$950.00 Payment Options

IN-PERSON CNA TRAINING CLASS6-week training consists of IN-PERSON classroom, in-person lab skills, and clinical training in a skilled nursing facility. Financing is NOT based on your credit score. See the terms below in the FINANCING section.

$750.00 Payment Options

Total

$0.00

Credit Card Details: Must be completed by ALL applicants
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

*FINANCING - CNA ONLINE ONLY - Must complete if selected "Pay half now" as a payment option. SKIP THIS SECTION if you selected "Pay in full" as your payment option.
*FINANCING - CNA IN-PERSON ONLY - Must complete if selected "Pay half now" as a payment option. SKIP THIS SECTION if you selected "Pay in full" as your payment option.
Disclaimer and Signature

If this application leads to acceptance to Visionary Health Career Training Institute, LLC, I understand that false or misleading information in my application may result in dismissal from the program.
Check the box to acknowledge:*

Payment will be processed according to the payment method you selected above. The total amount, including the application fee, is your responsibility and must be paid in full immediately. If any balance remains after your initial payment, you must finance it through Denefits. Please ensure that your payment arrangements with Denefits are finalized BEFORE the start of your classes.
Check the box to acknowledge:*

All deposits are NON-REFUNDABLE after 72 hours of application submission.
Check the box to acknowledge:*

A criminal background check MAY be required.
I HEREBY CERTIFY THAT ALL INFORMATION PROVIDED IN THIS AUTHORIZATION IS TRUE, CORRECT AND COMPLETE.
Signature*

Clear
Date*

MonthDayYear
Should be Empty:

CERTIFIED NURSING ASSISTANT STUDENT APPLICATION

Education

College

Other Education

References

Employment History

Military Service

Payment Options and Authorization

Disclaimer and Signature

I HEREBY CERTIFY THAT ALL INFORMATION PROVIDED IN THIS AUTHORIZATION IS TRUE, CORRECT AND COMPLETE.