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.

Last Name:
First Name:
Middle Initial:

Social Security Number:
Date of Birth:

Phone #:
Cell #:
Email Address:

 How did you hear about ANHO?

US Legal Status:

Health HistoryPlease list disabilitiesPlease explain any
accomodation you will need
Physical Problems  
Hearing Problems  
Speech Problems  
Sight Problems  
Emotional Problems  

    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?
    In the last 5 years, have you been treated for or had a recurrence of a diagnosed mental disorder or impairment?
    In the last 5 years, have you been treated for or had a recurrence of a diagnosed physical impairment?
    In the last 5 years, have you been treated for or had a recurrence of a diagnosed addictive disorder?

Education Level
    Graduated From High School/Recieved GED
    Associate Degree Obtained
    Bachelor's Degree Obtained

Please list all schools attended beginning with High School:
School NameAddressCourse of StudyYears AttendedDegree/ Diploma Earned

    Drivers License
    Restricted License
    Students are required to travel to a variety of clinical sites. Do you have the ability to comply with this requirement.

Work History
Dates EmployedCompany NameYour Position

Have you ever taken an examination for CNA, LPN, or RN Licensure?     
If YES, Please complete the following for all previous attempts:
ExaminationState Taken/CountryDate(MM/YYYY)Result

More Info if necessary:

I am presently employed at:
Company Name & Address: 
Position Held: 
Phone #: 
# of Hrs Worked/Week: 

I have been laid off from:
Company Name & Address:  

Are you a US Military Veteran?  (Please Check One)
  If so, are you eligable for GI Bill®Benefits?  
  Are you planning to use your GI Bill®Benefits?  

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

Criminal Background:
    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:
NameRelationshipPhone 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)