Providence Vocational School
189 School Street Daly City, CA 94014 | Tel: 650-991-2309 | Fax: 650-991-2047 | pvs189@yahoo.com

Application for Admission


Personal Information


Program Applying To:
Last Name: First Name: Middle Initial:
Address: Apt. #:
City: State: Zip:
Home Phone: Work Phone:
SSN: E-mail:
Who may contact in case of an emergency?
CNA Lic# HHA Lic# Exp.#
Emergency Contact Phone: Relationship:
Are you at least 18 years old? Yes No
Have you ever been convicted of a criminal offense by any court of law? Yes No

If Yes, please provide us with a signed statement indicating the nature and circumstances of the crime(s).

Referred to Providence Vocational School by:
 

Education Record


(Include all high school and all post high school education. List most recently attended schools first)

College/University
School Name: Degree Type:
City: State:
Dates of Attendance: Graduated? Yes No

Vocational/Business School
School Name: Degree Type:
City: State:
Dates of Attendance: Graduated? Yes No

High School
School Name: Degree Type:
City: State:
Dates of Attendance: Graduated? Yes No
 

Employment Record


(List most recent employment first. Be sure to include all nursing related experience)

Employer's Name:
Address:
Supervisor: Title: Phone:
Dates Employed: Job Title:
Duties:
Still Employed Here? Yes No Reason For Leaving:

Employer's Name: Address:
Supervisor: Title: Phone:
Dates Employed: Job Title:
Duties:
Still Employed Here? Yes No Reason For Leaving:

Affirmative Action Form


The Federal Office of Contract Compliance requires that we provide the following information under Affirmative Action Guidelines. The information provided is for statistical purposes only and does not remain with your file. Your privacy will be diligently protected by Providence Vocational School.

Please mark the categories which pertain to you. Mark only one in Section A and all appropriate categories in Section B.
Section A
Section B

It is understood by Providence Vocational School, Inc. that the information given above in no way affects your eligibility for enrollment or other benefits that Providence Vocational School offers.

IMPORTANT - READ BEFORE SENDING

I hereby certify that the facts set forth above are true and complete and I authorize Providence Vocational School to verify any and all of the statements that I have made. I also authorize all persons and institutions including my previous employers and the schools that I attended to provide Providence Vocational School with any information that it requests in connection with this application. I hereby release all of these persons and institutions and Providence Vocational School from my liability for any damages from the verification process.

Date: Signature:



© Providence Vocational School | 189 School Street Daly City, CA 94014 | Tel: 650-991-2309 |