(100 hours or more working
or volunteering within
the last 2 years.)
• Licensed LVN or
• Recent work
• Recent volunteer
-Proof of LVN or paramedic license is required to receive
the 10 points.
-License or certification copy required for listed work
-Written proof of volunteer hours, signed by institution
Examples of work experience:
• CNA, respiratory therapist, psych tech, radiology tech,
ultrasound tech, phlebotomist, medical assistant,
occupational therapy assistant, physical therapy assistant,
Examples of volunteer experience:
• hospital volunteer in patient care areas, long term care
volunteer, hospice volunteer
Choose one from the
following if it applies to
• Low Income
• 1st generation to
• Need to work
• Disadvantaged social
• Difficult personal and
Provide brief description on a separate piece of paper,
explaining situation or circumstances. Attach to this form.
Do you have eligible
veteran’s status or pending
Honorable Discharge. Submit copy of DD-214 and attach to
Do you have proficiency or
advanced level coursework
in languages other than
Completed Certificate of Language Proficiency Form.
Transcripts showing completion of 4 semesters at college
level in same language with “C” or better.
Submit an unofficial copy of TEAS results and attach to this
form. If you are selected for this program, you will need to
submit the official TEAS results to our office.
TEAS Score < 62 = not qualified
Total points available for all criteria is 105. Students with 70 or more points will be placed in a pool
for random selection. This form must be filled out, printed out, and attached to the application, along
with supporting documentation. The application will not be considered without supporting documents.