ASSOCIATES DEGREE NURSING PROGRAM APPLICATION (CONTINUED)
ATI TEAS:
Have you taken the TEAS? No Yes If yes, how many times have you taken the TEAS (all versions)? _____
If you have been invited to take the TEAS at LASC and did not show up please state reason why:
If you have taken the TEAS, unofficial results (all versions) must be submitted with your application. TEAS score must be submitted
officially by close of business on the submission deadline date. Late submissions will not be accepted.
1
st
Attempt: _________% Version: _______ Date:______________ Taken at:_____________________________________________
2
nd
Attempt: _________% Version: _______ Date:______________ Taken at:_____________________________________________
3
rd
Attempt: _________% Version: _______ Date:______________ Taken at:_____________________________________________
Offense/Fraud Question:
Have you ever been convicted of any offense other than minor traffic violations? No Yes
Have you had a misdemeanor in the past 7 years? No Yes
Are you currently on any type of probation? No Yes
If yes to any of the above questions, please submit a signed formal letter (typed) to Dr. Azubuike, the Program Director and attach it to the
application.
STUDENTS MUST ALSO SUBMIT A COPY OF CERTIFICATE OF REHABILITATION (expungement documentation) WITH APPLICATION.
Additionally, when
you complete the program, you
will be required
by the Board
of Registered Nursing, to
explain your conviction(s) and/or
arrest(s)
and submit additional information.
If you are a current CNA or LVN, have you ever committed or been accused of health care fraud? No Yes
If yes, was your license revoked or suspended? No Yes
Explain in a formal and signed letter to Dr. Azubuike, the Program Director along with paperwork indicating case has been resolved and
attach to application.
PLEASE READ AND INITIAL NEXT TO EACH BULLET
• I understand that the ability to submit an application does not guarantee selection.
• I am aware that I should check my LACCD email on a weekly basis for any news regarding the LASC ADN Program and that I
should check the LASC Nursing Program website on a weekly basis for any updates.
______ • I understand that if I have taken the TEAS, official results must be submitted by the application deadline. All submissions must be done
through the ATI website. Even if I take the TEAS after submission of this application I am expected to submit official results by assigned
date.
• I am aware that I will be notified, via my LACCD email, to take the TEAS, if needed.
______ • I understand that my application may not be considered for the selection pool and I may not be considered for the nursing program if the
TEAS exam is not taken on the assigned date.
I certify that the answers I have given are true and correct and I have not withheld any facts or circumstances. I understand that all
answers given are subject to verification, and any falsification, misrepresentation, or omission of facts are sufficient reason for dismissal
upon discovery at any time during enrollment in the nursing program. Any part of the application that is left blank will be considered
incomplete and will not be considered to the next phase
.
/ /
SIGNATURE DATE
First Name Student ID Number
Ml
• I am aware that there is a mandatory orientation I must attend if I get accepted into the program (dates to be announced).
• I have attached a clear copy of current California Identification/Driver's License (front & back).
