Please enter your first name.

Please enter your middle name.  If you do not have a middle name, please enter "N/A".

Please enter your last name.

Please enter a maiden name, or any other legal name you have ever had.  If you DO NOT have a maiden name, please enter "N/A".

Please enter your Social Security Number.  ONLY USE NUMBERS, NO (-) DASH MARKS!

Please enter your date of birth.

How old are you?

Please enter your street address here, please be sure to say St. Dr. or Ln.  There are many streets in one town only distinguished by street, lane, or drive.   DO NOT USE "ENTER" KEY, USE SPACE BAR AND COMMAS TO DISTINGUISH DIFFERENT LINES. MUST ALL BE ON ONE CONTINUOUS LINE!

What city do you live in?

Please pick the state you live in.  If your state is not listed, please select "Other".

Please enter your zip code.

Please enter the county that you live in.  If your county is not listed, please select "Other".

Please enter your Primary Phone Number here.  If your cell phone is your primary number, please enter that here. ONLY USE NUMBERS, NO (-) DASH MARKS!

Please enter your cell phone number here.  If your cell is your primary number, please also enter it here.  ONLY USE NUMBERS, NO (-) DASH MARKS!

Who do you contract with for your cell service?

What is your marital status?

What is your annual household income?

(Requested not Required) If you would prefer not to give us this information, please select "N/A".

If you are NOT a U.S. Citizen please indicate your type of Visa.  If you ARE A CITIZEN, please enter N/A

Have you attended Beck School of Practical Nursing in the past?

Do you have an Associates, Bachelor's, or Master's degree in ANY other field, regardless of type of profession?

Not Required

What is the name of your high school, which city, and state, did you graduate from?  If you DID NOT GRADUATE, PLEASE ENTER N/A. DO NOT USE "ENTER" KEY, USE SPACE BAR AND COMMAS TO DISTINGUISH DIFFERENT LINES. MUST ALL BE ON ONE CONTINUOUS LINE.

What year did you graduate high school?  Please ONLY give us the YEAR YOU GRADUATED HIGH SCHOOL. Numbers ONLY.  If you DID NOT GRADUATE, PLEASE ENTER FOUR NUMBER ZEROS (0000).

If you did NOT graduate High School, do you have a GED?  An official transcript in the original, sealed envelope must also be provided to the school from the place you received your GED.

Indicate in the box below: Current or most recent EMPLOYER name, location, type of work, dates, reason for leaving.  If you have no other employer, please ENTER N/A.  If you have no other employer, please ENTER N/A.  DO NOT USE "ENTER" KEY, USE SPACE BAR AND COMMAS TO DISTINGUISH DIFFERENT LINES. MUST ALL BE ON ONE CONTINUOUS LINE.

Indicate in the box below: SECOND EMPLOYER name, location, type of work, dates, reason for leaving.  If you have no other employer, please ENTER N/A.  If you have no other employer, please ENTER N/A.  DO NOT USE "ENTER" KEY, USE SPACE BAR AND COMMAS TO DISTINGUISH DIFFERENT LINES. MUST ALL BE ON ONE CONTINUOUS LINE.

Indicate in the box below: THIRD EMPLOYER name, location, type of work, dates, reason for leaving. If you have no other employer, please ENTER N/A.  If you have no other employer, please ENTER N/A. DO NOT USE "ENTER" KEY, USE SPACE BAR AND COMMAS TO DISTINGUISH DIFFERENT LINES. MUST ALL BE ON ONE CONTINUOUS LINE.

Indicate in the box below: FOURTH EMPLOYER name, location, type of work, dates, reason for leaving. If you have no other employer, please ENTER N/A.  DO NOT USE "ENTER" KEY, USE SPACE BAR AND COMMAS TO DISTINGUISH DIFFERENT LINES. MUST ALL BE ON ONE CONTINUOUS LINE.

Indicate a PROFESSIONAL, NON-Family member in the box below: name, relationship, mailing address, & phone number.  DO NOT USE "ENTER" KEY, USE SPACE BAR AND COMMAS TO DISTINGUISH DIFFERENT LINES. MUST ALL BE ON ONE CONTINUOUS LINE.

Indicate a PROFESSIONAL, NON-Family member in the box below: name, relationship, mailing address, & phone number.   DO NOT USE "ENTER" KEY, USE SPACE BAR AND COMMAS TO DISTINGUISH DIFFERENT LINES. MUST ALL BE ON ONE CONTINUOUS LINE.

Indicate a PROFESSIONAL, NON-Family member in the box below: name, relationship, mailing address, & phone number.  DO NOT USE "ENTER" KEY, USE SPACE BAR AND COMMAS TO DISTINGUISH DIFFERENT LINES. MUST ALL BE ON ONE CONTINUOUS LINE.

Do you have any Licensure or Certification?  In the box below indicate:  State of licensure, TYPE of licensure or certification, Lic/Cert. number, issue date, status (active, lapsed, etc.).  If you have NO CERTIFICATION, PLEASE ENTER N/A.  DO NOT USE "ENTER" KEY, USE SPACE BAR AND COMMAS TO DISTINGUISH DIFFERENT LINES. MUST ALL BE ON ONE CONTINUOUS LINE.

Do you have any Licensure or Certification?  In the box below indicate:  State of licensure, TYPE of licensure or certification, Lic/Cert. number, issue date, status (active, lapsed, etc.).  If you have NO CERTIFICATION, PLEASE ENTER N/A.  DO NOT USE "ENTER" KEY, USE SPACE BAR AND COMMAS TO DISTINGUISH DIFFERENT LINES. MUST ALL BE ON ONE CONTINUOUS LINE.

Do you have any Licensure or Certification?  In the box below indicate:  State of licensure, TYPE of licensure or certification, Lic/Cert. number, issue date, status (active, lapsed, etc.).  If you have NO CERTIFICATION, PLEASE ENTER N/A.  DO NOT USE "ENTER" KEY, USE SPACE BAR AND COMMAS TO DISTINGUISH DIFFERENT LINES. MUST ALL BE ON ONE CONTINUOUS LINE.

How did you hear about Beck School of Practical Nursing?

Have you been convicted of any criminal offense in any state or in federal court (other than minor traffic violations)?  If yes, forward to BSPN a certified copy of the court records regarding your conviction, the nature of the offense, and the date of discharge, if applicable, as well as a statement from the probation or parole office.

Have you been convicted of a felony?

Have you had or do you now have any disease or condition that interferes with your ability to perform the essential functions of this profession, including any disease or condition generally regarded as chronic by the medical community, i.e., (1) mental or emotional disease or condition; (2) alcohol or other substance abuse; (3) physical disease or condition, that interferes with your ability to practice this profession?

Have you ever been denied a professional license or permit, or privilege of taking an examination, or  had a professional license or permit disciplined in any way by any licensing authority in Illinois or elsewhere?

Have you ever been discharged, other than honorably, from the armed services or from a city, county, state or federal position?

In accordance with 5 Illinois Compiled Statutes 100/10-65(c), applications for renewal of a license or a new license shall include the applicant’s Social Security number, and the licensee shall certify, under penalty of perjury, that he or she is not more than 30 days delinquent in complying with a child support order.  Failure to certify shall result in disciplinary action, and making a false statement may subject the licensee to contempt of court.  Are you more than 30 days delinquent in complying with a child support order?

In accordance with 20 Illinois Compiled Statutes 2105/2015-(5), “The Department shall deny any license or renewal authorized by the Civil Administrative Code of Illinois to any person who has defaulted on an educational loan or scholarship provided by or guaranteed by the Illinois Student Assistance Commission or any governmental agency of this State; however, the Department may issue a license or renewal if the aforementioned persons have established a satisfactory repayment record as determined by the Illinois Student Assistance commission or other appropriate governmental agency of this State.”  (Proof of a satisfactory repayment record must be submitted.)  Are you in default on an educational loan or scholarship provided/guaranteed by the Illinois Student Assistance Commission or other governmental agency?

I understand that my Financial Aid history and eligibility will be reviewed as part of my application process.

Please read the following in its entirety and select the box next to each statement, as this will acknowledge your acceptance of each.  You will be required to sign the submitted application at the time of your interview.

I give my permission for the Practical Nursing Director or his/her designee to contact any persons listed as references or employers for the purpose of clarifying information in my student file or to obtain additional information at the Practical Nursing Director’s discretion.

I understand that any falsification or omission of information in application to the Practical Nursing program is seen as fraud and is cause for me not being accepted to or for my immediate dismissal from the program.

Applicants are reminded that licensing boards may deny, suspend or revoke a license or may deny the individual opportunity to sit for an examination if an applicant has a criminal history or is convicted or pleads guilty or nolo contendere to a felony or other serious crime.  Successful completion of a health professions program of study at the Career Center of Southern Illinois and Beck School of Practical Nursing does not guarantee licensure, the opportunity to sit for a licensure examination, certification or employment in the relevant health care occupation.

Career Center of Southern Illinois and Beck School of Practical Nursing does not discriminate because of race, age, color, sex, religion, national origin, handicap, or status as veterans:

I have read the information provided in this application and am familiar with its contents.  By signing this form, I certify under penalty of criminal prosecution that all information on this form and any additional supporting information submitted with my application packet are true and correct to the best of my knowledge.