New Era Nursing And Training Form

APPLICATION FORM

Complete the personal details and program request, then submit the form to request your placement test date.
Personal Information
Last Name
First Name
Middle Name
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Address Line 2
City
State
Home Phone #
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Native Language
Date of Birth

MonthDayYear
Date
Sex
Program Applying For
Experience & How You Heard About Us
Note
Have you worked in the health care field before?
If yes, please describe your experience
How did you hear about this course?
NOTE
Return-to Address: New Era Nursing Training Service, 7531 Diplomat Dr, Suite 101, Manassas, VA 20109
Warning: The ZIP code in the source image appeared cut off/unclear as 2010 and should be confirmed before publishing.
SECTION 5 — Admission Requirements

ADMISSION REQUIREMENTS

Complete the admission application ($50.00 non-refundable fee)
Provide appropriate ID
Entrance test for those who do not have a high school diploma or GED
Virginia State background check
First down payment of $500.00 must be paid on or before the first day of class
Payment plan consists of paying $200.00 every week
All payments will have to be completed before the end of the course.

MEDICAL/HEALTH OR OTHER ITEMS NEEDED PRIOR TO CLINICAL ROTATION

PPD test, MMR, or negative chest X-ray — must be turned in 7 days before start of class
Clinical badge
Uniform: purple top, white bottom and skirt, and white shoes
CPR and First-Aid certification
Day/evening and weekend classes are available

ORIENTATION
Begins on the first day of Saturday before classes start

TUITION AND OTHER COST — PAYMENT PLAN AVAILABLE

Item	Cost
Books	$100.00
Tuition	$1,300.00
CPR and First Aid	$100.00
State Board Exam	$120.00

Disclaimer text to display: Upon successful completion of the approved Certified Nursing Assistant Program, you will be eligible to apply for the state certification. Please be aware that NEW ERA NURSING AND TRAINING SERVICES accept no liability for any accident or injuries that may occur during the course or training sessions.

Request for Test Date
Instruction
Requested Test Date

MonthDayYear
Date
Requested Test Time

Hour Minutes

AM/PM Option
E-Signature
Signature
Date

MonthDayYear
Date
Should be Empty:

APPLICATION FORM

Personal Information

Experience & How You Heard About Us

SECTION 5 — Admission Requirements

Request for Test Date

E-Signature