Name and Address of 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
