North Central Kansas
Technical College
PO Box 507 2205 Wheatland Ave
Beloit, KS 67420 Hays, KS 67601
800-658-4655 785-738-2276 888-567-4297 785-625-2437
785-738-9025 Nursing Program 785-623-6155 Nursing Program
Application for Admission
Indicate program for entry School Year 2021 - 2022
Hays Campus - _____
First Year (LPN) Beloit Campus (LPN)- _____
_____ Second Year (RN)
Social Security Number _______________________________ Date _______________________
Name ______________________________________________________________________________
Last Maiden First Middle
Date of Birth ___________________________________
Address _____________________________________________________________________________
Current Address Street City State Zip
County ____________________ e-mail address: ______________________________________
Address _____________________________________________________________________________
Permanent (if different then present address)
Telephone ________________________ __________________________ _______________________
Cell Work Permanent Home
Emergency Contact ____________________________________________ ______________________
Name Relationship
Address City State Zip
_____________________________ ____________________________
Telephone (Home) Telephone (Daytime)
Optional Information (Used for reporting purposes)
Race: _____ African American _____ American Indian _____ Asian _____ Hispanic _____ White _____ Other
Gender: _____ Male _____ Female
Name and Address of School
Last Year
Degree Earned
Last Year
High School
Business or
Trade School
I certify that to the best of my knowledge all statements that I have made on this application are complete
and true. Additionally, I have completed the items on this application in their entirety and I will provide
NCKTC the documents required as a condition of admission and enrollment.
_________________________________________________ ________________________________
Signature of Student Date
Please return completed application to Nursing Program Admissions:
PO Box 507 2205 Wheatland Ave
Beloit, KS 67420 Hays, KS 67601
NCK Tech is committed to nondiscrimination on the basis of race, color, gender, ethnic or national origin, sex,
sexual orientation, gender identity, marital status, religion, age, ancestry, disability, military status, or veteran
status in admission or access to, or treatment or employment in, its programs and activities. Further, it is the policy
of the college to prohibit harassment (including sexual harassment and sexual violence) of students and employees.
Any person having inquiries concerning the college's compliance with the regulations implementing Title VI, Title
VII, Title IX, Section 504, and the Americans with Disabilities Act Amendments Act is directed to the Dean of
Instructional Services (Section 504/ADA Compliance Officer) or the Dean of Student Services (Title VI, Title VII, &
Title IX Compliance Officer) at 1-800-658-4655 or PO Box 507, 3033 US Hwy 24, Beloit, KS 67420.
Any convictions either prior to or during the school year may jeopardize eligibility for licensure.
Adopted 08/98
Revision 06.19