CERTIFIED NURSING ASSISTANT APPLICATION
Community Education Center Campus
Health Sciences Division B6
3035 East Foothill Blvd.
Pasadena, CA 91107
PRINT your information CLEARLY
Print Name:
Last First
*Social Security #xxx-xx- PCC Student ID #
Note: You MUST apply to the College (www.pasadena.edu click on apply) in order to obtain a
PCC Student ID required for this application.
*A social security number is required by the California Department of Public Health Licensing
and Certification Program.
Address:
City: Zip:
PCC Email:
Home Email:
Home Phone #:
Cell Phone #:
Are you a U.S. Veteran or spouse of a U.S. Veteran? YES (if yes please provide a copy of
your DD214). No, I am not a U.S. Veteran or spouse of a U.S. Veteran.
If you are the spouse of a U.S. Veteran, a copy of the marriage certificate is also required.
Provide an official transcript of a United States High School education, GED, Foreign
Equivalency Evaluation or an official college transcript showing an Associate or higher
degree with this application. Incomplete and late applications will not be processed.
My signature below indicates that I have provided true and accurate information on this
application and that I understand that final acceptance to the course will be based on a criminal
background check in addition to a completed health clearance form. Submission of an
application does not guarantee acceptance.
Signature Date
Revised: 8/8/16 February 1 – March 1 = Summer Course September 1 – October 1 = Winter Course
click to sign
signature
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