Student Application Form - Mednoc Training College

MTC Student Application Form

STUDENT APPLICATION
MedNoc Training College does not discriminate in its admission decisions on the basis of race, color, sex, religion, citizenship, national origin, veteran status, age or upon a physical or mental disability which is unrelated to the applicant’s ability to perform study and perform clinical functions required in this course.
Date Of Application *
Which Class Schedule are you Enrolling *
Morning 8.00Am-3.00PmAfternoon/Evening 3.00pm-9.30pm or 5.30-9.30pmWeekend 8.00Am-5.00Pm
When do you want to start your classess? Please write the month: *
Last Name *
First Name *
Middle Name
Social Security No *
Email Address *
Drivers Licence / State ID *
List any other name(s) you have previously used in any legal document, such as maiden name

Present Address

Street Address *
City *
State *
Zip Code *
Permanent Address (if different than present address):
Street Address
City
State
Zip Code
Cell Phone *
Date of Birth *
Telephone *
Sex *
MaleFemale
Race *

US Military Record

Branch
Date Entered
Date Discharged
Type Of Discharge

Employment

Employers Name *
Telephone Phone *
Employers Address *
Position Held *
Supervisor:
Dates Employed: From(month/year) *
Dates Employed: To(month/year) *

Education Background

Institution(High School, Technical School, College) *
Type Of Studies *
Dates Attended && Diplomas e.t.c *
Institution(High School, Technical School, College)
Type Of Studies
Dates Attended && Diplomas e.t.c
Institution(High School, Technical School, College)
Type Of Studies
Dates Attended && Diplomas e.t.c
Institution(High School, Technical School, College)
Type of Studies
Dates Attended && Diplomas e.t.c
If your school or employment records are under another name(s), indicate that name(s)

References

List name, address and telephone number of three (3) references who are not relatives or former employers.
Name *
Address *
Telephone *
Name *
Address *
Telephone Number *
Tell us briefly why you are choosing your program of study? *

Background Information

If you answer YES to any of the questions below, explain in the space after the question. The explanation for a YES answer should include, but not be limited to:
- 1. State and/or jurisdiction
- 2. Nature of Complaint/offense
- 3. Disposition of complaint and/or offense (e.g "dismissed insufficient evidence", "deferred sentence")
- 4. Attach copy of any correspondence received by you, the applicant, regarding the complaint/offense
*
Have you ever: 1) participated in a first offender program; 2) deferred adjudication or other program or arrangement where adjudication has been withheld; 3) plead guilty or no contest; 4) been convicted; 5) received a deferred sentence; and/or 6) been sentenced for any criminal offense in any state or US jurisdiction regardless of whether this matter has been expunged or otherwise removed?YesNo
Have you ever been found in violation of any state, US jurisdiction, or federal law regulating the Practice of a health care profession? *
YesNo
Are any disciplinary actions or allegations, pending or substantiated, against you or your Certification or health care professional license in any state or U.S. jurisdiction? *
YesNo
Have you had any certificate, license, registration or other privilege to practice a health care profession denied, revoked, suspended, restricted, reprimanded, censured or placed on probation by a state or US jurisdiction, federal or foreign authority or have you ever surrendered such credential to avoid, or in connection with, action by such authority?YesNo
Explain Here if any of the above is Yes

Applicant’s Certification and Agreement

Please Read Carefully - If you answer No to any of the questions below, explain in the space after the questions.
I understand that MedNoc Training College has the right to proceed with any criminal background check *
YesNo
*
I understand as a part of the training/clinical process, I may be required to take a drug-screening test at the time of starting clinical rotations and if requested in accordance with the state and federal law at any time during my training at MedNoc Training College. A test result that has been confirmed as positive will eliminate me from attending clinical sites. If I refuse to sign this form and submit to drug testing, the MedNoc Training College will reject my application or drop me from the training programYesNo
I understand I may be required to have a physical examination and I hereby consent to take a physical examination and any future physical examinations as required by the clinical sites/ facilities *
YesNo
I understand if I am admitted I will be required to produce proof that I have a legal right to work in the U.S.A. in accordance with the IRCA of 1986. *
YesNo
I certify that I have read and completed this student application form, and that all the information provided is true, and complete to the best of my knowledge and ability. I further understand that providing false information is ground for denial of my application and admission to MTC. In addition, I certify that all documents, submitted in support of this application are true to the best of my knowledge. By signing this below I agree to enroll in the course of study that I have selected. If the student is less than 18 years of age the parent or legal guardian must sign this enrollment application and agreement form. The parent or legal guardian must provide a copy of government issued photo ID and social security card.
Student Name
Digital Signature Of Applicant

Verification

Please enter any two digits *Example: 12
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Call Today: (405) 225-7876|Email: info@mednoc.com

MTC Student Application Form

Present Address

First Emergency Contact

US Military Record

Employment

Education Background

References

Background Information

Applicant’s Certification and Agreement

Verification