Student Application

First Name *

Last Name *

Middle Name *

Email *

Phone *

Social Security No. *

Program Applying For *

Street Address *

Street Address Line 2 *

City *

State *

Postal / Zip code *

Are you a citizen of the United States? *

Yes

No

Have you ever applied to Visionary Health Career Training Institute? *

Yes

No

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

Yes

No

Have you ever been a Certified Nursing Assistant? *

Yes

No

Have you ever been convicted of a felony? *

Yes

No

If convicted, please explain

Education

High School

High School address

High School Start Date

High School End Date

Did you graduate high school?

Yes

No

Diploma/GED

Diploma

GED

College

College address

College Start Date

College End Date

Associate/Bachelor's

Assoiciates

Bachelors

N/A

Did you graduate college?

Yes

No

Other

Other Education

Other Education address

Other Education Start Date

Other Education End Date

Did you graduate Other Education?

Yes

No

Other Education Degree

References

Full Name

Relationship

Company

Phone

Address

Full Name

Relationship

Company

Phone

Address

Full Name

Relationship

Company

Phone

Address

Employment

**You do not have to list three jobs if you had fewer**

Employment:

Phone

Address

Supervisor

Job Title

Starting Salary

Ending Salary

Responsibilities

From

To

Reason for Leaving

May We Contact Supervisor?

Employment:

Phone

Address

Supervisor

Job Title

Starting Salary

Ending Salary

Responsibilities

From

To

Reason for Leaving

May We Contact Supervisor?

Employment:

Phone

Address

Supervisor

Job Title

Starting Salary

Ending Salary

Responsibilities

From

To

Reason for Leaving

May We Contact Supervisor?

Military Service

Branch

From

To

Rank At Discharge

Type Of Discharge

If Other Than Honorable, Explain

Disclaimer and Signature

If this application leads to acceptance to Visionary Health Career Training Institute. I understand that false or misleading information in my application may result in dismissal from the program.

Your Full Name

Date

Consent To Perform Criminal History Background Check

Date

Driver's License #

State Issued:

First Name

Last Name

Middle Initial

Maiden And/Or Other Last Names Used

Date of Birth

Social Security Number

Street Address

Choose an Option: (Male/Female)

City

Region/State/Province

Postal / Zip code

This authorization and consent for release of personal information acknowledges that Visionary Health Career Training Institute (Hereafter referred to as "Company") and/or its agent, may now, or at any time I am assigned to, volunteer with or attending classes or am employed by this Company, conduct investigations whether the records are of a public, private or confidential nature. These investigations might include, but are not limited to, searches of educational institutions attended; financial or credit institutions, including records of loans; records of commercial or retail credit agencies; other financial statements; records of previous employment, including work history, efficiency ratings, complaints and grievances filed by or against me; records and recollections of attorney-at-law or of other counsel, whether representing me or any other person (in either a civil or criminal case in which I have been involved); records from the U.S. Veterans' Administration; criminal history information of file in local, state or federal agencies; and motor vehicle records, and following an employment offer, workers' compensation reports from either the Department of Labor, National Personnel Records or the Industrial Commission or similar agencies under the provisions of the Fair Credit Reporting Act 15, USC section 1681 et seq.

I understand that these searches will be used to determine school assignment or employment eligibility under the company's school admission, employment or volunteer policies. Therefore, I authorize and consent for full release of records (either orally or in writing) to the authorized representatives of the company. In addition, I release and discharge the company and its agent and associates to the full extent permitted by law from any claims, damages, losses, liabilities, costs expenses or any other charge or complaint filed with any agency arising from retrieving and reporting this information. I understand that per the Federal Fair Credit Reporting Act, I am entitled to know whether enrollment was denied based upon the information obtained and to receive, upon written request, a disclosure of the background report. I also understand that I may request a copy of the report by contacting Visionary Health Career Training Institute.

I agree to the terms & conditions

The following are my responses to questions about my criminal record history (if any) with descriptions to any question with a YES answer:

Have you ever been convicted or plead guilty before a court of any federal, state, or municipal criminal offense? (Excluding minor traffic violations) If YES please provide an explanation below:

Yes

No