MODESTO JUNIOR COLLEGE
NURSE ASSISTANT
Program Application
Last Name
First Name
MI
other last names
City State
Zip
So
cial security Number
Gender:
Ethnic Group: (response optional but appreciated)
American Indian/Alaskan Native
Black/African American
Anglo
Filipino
Asian/Pacific Islander
Hispanic
Are you
Bilingual? If yes, what language(s)?
Is English your primary language? If no, what is your primary language?
Have you ever been convicted by any court of a crime, other than a minor traffic violation?
If Yes, there is additional information available on
the cdph.ca.gov website.
☐ By checking this box, I understand that in order to complete the state exam I must provide an original social
security card, not copied or laminated.
☐ By checking this box, I also understand that in order to complete the state exam, if my address has changed it
must be updated on my government issued ID. Or I must provide the DMV issued change of address card.
I certify under penalty of perjury that all information contained herein is correct, and understand that the
penalty for submitting fraudulent information for acceptance into the program is immediate dismissal and
withholding of grades.
Signature Date
Street Address
Date of Birth
PhoneStudent Email Address
Person to call in case of emergency:
Last Name
First Name
Relationship
Phone
State Exam Requirements:
Rev. 5-27-2020 JM
@my.yosemite.edu
Personal Email
click to sign
signature
click to edit
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