UNIVERSAL TRAINING INSTITUTE INC
LPN APPLICATION FORM

 

NOTE: You need to be certified or licensed in the US, you must live and work in the US and undergo a criminal background check.

 

PERSONAL DATA - PART I

 

Social Security Number

 

Full legal name

 

Mailing Address

 

Permanent Address

 

Telephone Number

 


PERSONAL DATA - PART II

This section is for statistical purposes only, acceptance is granted with no regard to race or national origin. Please check all that may apply.

 

Gender
MaleFemale
Date of Birth

 

Marital Status
SingleMarriedOther
Specify (if other)

 

Citizenship
US Citizen
Visa Status
Type (if other):
Green Card
Other

 

Specify (if other):

 

Ethnicity: This section is optional if you prefer NOT to complete the ethnicity section, please INITIAL HERE

 

African AmericanAsianCaucasianHispanicNative AmericanPacific Islander/CaribbeanOther

 


PERSONAL DATA - PART III

 

Have you ever been convicted of a criminal or military offence, excluding minor traffic violations?

Yes (if answered yes, please read bold face section below)No

 

Have you ever been academically dismissed from, declared ineligible to attend or incurred action at any previous institution?

Yes (if answered yes, please read bold face section below)No

 


If you answered "Yes" to any of the above questions, you may be required to attend a personal interview with an Administrative Representative for further evaluation.


ACADEMIC INTEREST: Please check all that may apply  

Day Session: Mon - Thurs, 8:30 am to 4:00 pmEvening Session: Mon - Thurs, 6:00 pm to 10:00 pm

 

How did you hear about Universal Training Institute? (Check all that may apply)

FriendMailingInternetSchool WebsiteWalk InUnemployment/WorkforceNewspaper

 


EMPLOYMENT DATA
Employment History: Please list most recent employees in the last three years. Start with the most recent or current. Dates must reflect months and years (For Example: Start Date 12/11 - End Date 01/13)

 


EDUCATIONAL DATA - PART I
HIGH SCHOOL INFORMATION:

 

Date of Graduation
Grade Point Average (GPA)

 


EDUCATIONAL DATA - PART II
PREVIOUS COLLEGES, UNIVERSITIES, CAREER TRAINING SCHOOLS ATTENDED:

 


Please list three (3) references. Please EXCLUDE all relatives, spouses and children

 

 

 


APPLICANT AGREEMENT
I certify that the information given in the Registration Form is true and correct to the best of my knowledge.
I recognize that withholding or misrepresenting information my result in cancellation of my acceptance.