PROGRAM APPLICATION FORM
PROSPECT INFORMATION
This application is to be submitted with a $150.00 non-refundable registration fee.
Program
...
Associate of Science in Nursing (ASN)
Medical Coding & Billing (MCB)
Substance Addiction Studies (SAS)
Last name
First Name
Street
City
State/Province
...
Alabama
Alaska
Alberta
American Samoa
Arizona
Arkansas
Armed Forces
Armed Forces Americas
Armed Forces Pacific
British Columbia
California
Colorado
Connecticut
Delaware
District of Columbia
Federated States of Micronesia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Manitoba
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Brunswick
New Hampshire
New Jersey
New Mexico
New York
Newfoundland
North Carolina
North Dakota
Northern Mariana Islands
Northwest Territories
Nova Scotia
Nunavut
Ohio
Oklahoma
Ontario
Oregon
Palau
Pennsylvania
Prince Edward Island
Puerto Rico
Quebec
Rhode Island
Saskatchewan
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Yukon
N/A
Zip/Postcode
Cell Phone
Alternative Phone Number
Email
Birth Date
Sex
...
Male
Female
Pheno Heritage
...
Alkebulan (misnomer, black/African/African-American)
Asian (misnomer, Native American Indian/Asian/Pacific)
European (misnomer, white/Hispanic/non-Hispanic)
Nationality
U.S. Citizen?
Yes
No
Not Selected
U.S. Permanent Resident?
Yes
No
Not Selected
EMERGENCY CONTACT INFORMATION
Last Name
First Name
Relationship
Cell Phone
Alternative Phone Number
EDUCATIONAL BACKGROUND
Did you obtain a High School Diploma/GED?
Yes
No
Not Selected
If so, Please indicate the city and State/Country?
High School Graduation Year
Have you attended any other institutions of Advanced Education?
Yes
No
Not Selected
If yes, please provide the name(s) and Date(s)
Upload a copy of your Transcript (Unofficial acceptable for initial application submission)
Any prior Medical Training?
Yes
No
Not Selected
If yes, please identify type of training, name of school, dates of attendance, and type of certificate or diploma received.
Are you a LPN license holder?
Yes
No
Not Selected
(For ASN applicants only)
EMPLOYMENT
Name of Employer:
Your Position or Job Title
Employed From:
Employed To:
Upload your resume
Have you ever been arrested and/or convicted of a crime?
Yes
No
Not Selected
If so, please explain.
DECLARATION
Prospect’s Signature
Payment Information
Items
Amount
Tuition
$0.00
Total
$0.00
Payment Method
Credit Card - PP
Required
First Name (as on card)
Same as applicant first name
Required
Last name (as on card)
Same as applicant last name
Required
Phone Number
Required
Email
Required
CardHolder Name
Required
CardHolderID / RIF
Required
Credit Card Number
Required
Expiration Date
1 - January
2 - February
3 - March
4 - April
5 - May
6 - June
7 - July
8 - August
9 - September
10 - October
11 - November
12 - December
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
Required
Security Code
Required
Currency
USD
Account Number
Required
Routing Number
Required
Applicants for admission to NURU Health Institute with any record of a stated criminal charge must report this information in the admission process. Assessment will be made accordingly through the office of the Program Director in order to finalize acceptance. Equally, any charges that may arise after admission to the institute must also be reported to administration. Failure to comply, upon discovery, will result in the immediate withdrawal from the program and expulsion from the institute at large, no exceptions.
Enter the above code
Required