Application

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Application

Are you over 18 years old
Have you ever been convicted by any government agency of child, patient resident or elderly abuse?
Are you being sponsored by a Medical certified facility?

If yes, you are not responsible for any costs associated with traning including the cost of textbooks and/or supplies

SPONSOR'S INFORMATION

EDUCATION

School Name & Address

Start Mo/Yr

End Date Mo/Yr

Did You Graduted?

Degree

COLLEGE UNIVERSITY

School Name & Address

Start Mo/Yr

End Date Mo/Yr

Did You Graduted?

Degree

OTHER CERTIFICATIONS

Employment History (Most Recent Employment First)

Employer Name and Address

Start Date Mo/Yr

End Date Mo/Yr

Position Held

CPR Certified ?
Who Referred You to us ?

Please Check Course You Are Applying for:

Please Refer to "About Us" for the requierments and schedule to select your date

*****$25.00(Twenty_Five dollor) application fee required non-refundable

I certify that the information provided in this applicatioun is true and complete to the best of my knowledge
i agree that if i misrepresent my self or omit any relevant information or provide false answer,
serenity nurse aids academy will disqualify me or discharge me from the program without refund.
(** If you have been convicted of a felony you can not enroll in Serenity Nurse Academy***)

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