COMPLETE ALL ITEMS (Please type or print clearly using black or dark blue ink.)  Mail to Claredonchc P.O. Box  221 Vicksburg, MS 39180

Applicant Information:

1. Full legal name ______________________________________________________________________________________________
                                         First                      Middle                         Last                    2. Other Name(s) Used (if applicable):  (Nickname or
Preferred Name _________________________________________________________________________________
3. Home Address                       City State/Province Country                                 Zip/Postal Code
4. Date of birth Month Day Year                                   5.  Age                        6. Gender Female Male write in option:_______________

7. State of Birth      8. Country of Citizenship If not a U.S. citizen, other, specify country                    Government Information ________________________ Country of birth: ______________________ US Permanent Resident visa; citizen of  ____________________________ Other Visa Type _____________________________________________         
Alien registration number ______________________________________________________________________________________________
Other Citizenship                                              Visa                                                                        Expiration Date
If you live in the United States, but are not a U.S. citizen, how many years have you lived in the country?
9. Permanent mailing address______________________________________________________________________
Number and street or PO Box Apt. City State Zip Code 10. Current address, if different from permanent address


Number and street or PO Box Apt. City State Zip Code
Social Security Number (Optional)                                             Email Address
10. Home Telephone Number (include country, city, and area codes)       11. Cellular or Message Telephone

________________________Home__________________________Cell ____________________________Fax
Number (include country, city, and area codes) 12. Fax Number (include country, city, and area codes)
Text messages may be sent at this number. Yes ____ No ____
13. Emergency contact full name
_____________________________________________________________________________________Who should be contacted in case of an emergency? Relationship to you (check one): Parent Guardian Spouse Partner, etc... Other Emergency contact physical address
Number and street Apt. City State Zip Code
Emergency contact phone: HOME   ____________________    CELL/MOBILE  _______________________
14. Ethnicity and Race Information (optional). Information you provide will not be used in a discriminatory manner.  Are you Hispanic or Latino Yes ____ No ____ (country of family’s origin: Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race).  Which of the following best describes your ethnicity? (select one or more of the following categories):  _____ Asian (country of family’s origin: Far East, Southeast Asia, or the Indian Subcontinent for example, China, India, Japan, Korea, Cambodia, Pakistan, the Philippine Islands, Thailand, and Vietnam) _____ Native Hawaiian or Other Pacific Islander  _____ Black or African American _____ White American _____ Indian or _____ Alaska Native Tribal affiliation).
This college is an Equal Opportunity/Affirmative Action institution and subject to certain reporting and affirmative action requirements. The information required on this page is requested only so that we may satisfy group statistics for federal, state, and institutional reports.
15.  Are you at least 18 years of age? Yes ____ No ____  Do You Plan to Apply for Financial Aid? ____ Yes ____ No   
16. Are you eligible for VA benefits? Yes ____ No ____
17. Criminal Background Self-Disclosure Other than traffic violations, have you ever been convicted of a criminal offense? Yes ____ No ____ What was the nature of the crime? ________________________________________________________ When did the conviction occur? ________________________________________________________ If Yes  Misdemeanor or Felony ________________________________________________________

Note: Please do not answer "yes" or provide any information about convictions that have been erased, expunged, erased, pardoned, sealed, annulled, vacated, set aside and/or otherwise eradicated by a court.

High School Graduate: Yes ____  No ____ If yes  date of graduation (expected) (M/YR)____ / _______  
G.E.D  Yes ____   No ____     I plan to receive a G.E.D  Yes ____  No ____

Check Applicable Program of Study    ______ CNA    ______ ASN 
I certify that all answers made in this application are true and correct to the best of my knowledge and belief.   I understand that providing false or incomplete answers could disqualify me from acceptance or terminate my enrollment  

_________________________________________ (Signature).

Education History
Most Recent or Current Courses
(Please list name, semester/trimester and credit hours/values for each course)
Trimester/semester 1                                Trimester/semester 1                              Trimester/semester 1
___________________________      __________________________        __________________________
___________________________      __________________________        __________________________
___________________________      __________________________        __________________________
______________________________         _____________________________           _____________________________
______________________________          _____________________________           _____________________________
List all high schools, colleges/universities (include summers), and academic programs you have attended. You must submit transcripts from each school.

High School Name                                     Dates attended                                          Location
___________________________      __________________________        __________________________
___________________________      __________________________        __________________________
___________________________      __________________________        __________________________
College/University Name                            Dates attended                                          Location
___________________________      __________________________        __________________________
___________________________      __________________________        __________________________
___________________________      __________________________        __________________________