Academy for Nursing and Health Occupations

A Private, Not-for-Profit, Licensed and Nationally Accredited College of Nursing

Where dreams of a Better Tomorrow Come True … Learn, Grow, Become …

Located at:
5154 Okeechobee Blvd
West Palm Beach, FL 33417
Phone: (561)683-1400
Fax: (561)683-6773
Email Us

Lois M. Gackenheimer Richards, PhD Ed, MSN, RN
Executive Director / President

Online Application

You must fill in all fields and submit the form in order for it to be received by the school.

	How did you hear about ANHO?

Last Name:
First Name:
Middle Initial:

Social Security Number:
Date of Birth:
Age:
How many years until you retire?:

Address:
City:
State:
Zip:
Phone #:
Cell #:
Email Address:

US Legal Status:	US Citizen Resident Alien Non-Resident Alien

Health History		Please list disabilities	Please explain any accomodation you will need
Physical Problems	Yes No
Hearing Problems	Yes No
Speech Problems	Yes No
Sight Problems	Yes No
Emotional Problems	Yes No
Other:

Yes No	In the last 5 years, have you been enrolled in, required to enter into, or participated in any drug or alcohol recovery program or impaired practitioner program?
Yes No	In the last 5 years, have you been treated for or had a recurrence of a diagnosed mental disorder or impairment?
Yes No	In the last 5 years, have you been treated for or had a recurrence of a diagnosed physical impairment?
Yes No	In the last 5 years, have you been treated for or had a recurrence of a diagnosed addictive disorder?

Education Level

Yes No	Graduated From High School
Yes No	Received GED
Yes No	Bachelor's Degree Obtained

Please list all schools attended beginning with High School:

School Name	Address	Course of Study	Years Attended	Degree/ Diploma Earned

Transportation

Yes No	Drivers License
Yes No	Restricted License
Yes No	Students are required to travel to a variety of clinical sites. Do you have the ability to comply with this requirement.

Work History

Dates Employed	Company Name	Your Position
	1.
	2.
	3.
	4.
	5.
	6.

I am presently employed at:

Company Name & Address:
Position Held:
Supervisor:
Phone #:
Salary:

I have been laid off from:

Company Name & Address:

Are you a US Military Veteran?	Yes No(Please Check One)
If so, are you eligable for GI Bill^®Benefits?	Yes No
Are you planning to use your GI Bill^®Benefits?	Yes No

List any skills, certifications, licenses or special training you have:

Criminal Background:

Yes No

Have you ever been convicted of, or entered a plea of guilty, nolo contendre, or no contest to, a crime in any jurisdiction other than a minor traffic offense? You must include all misdemeanors and felonies, even if adjudication was withheld and even if you were a juvenile. Driving under the influence (DUI) or driving while impaired (DWI) is not a minor traffic offense for the purposes of this question.

Please Explain: *You must have arrest and court records of final disposition for each offense listed.

Program Applying For:

In the event that we are unable to contact you at the phone number you have given please provide two(2) additional contacts:

Name	Relationship	Phone Number

In connection with my application to the Academy for Nursing and Health Occupations, I understand that a consumer report, which may contain public records information is being requested

Electronic Signature Date

(Typing your name here is equivilant to signing the application by hand)

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