RN/LPN Enrollment Information Form

First name

Last name

Phone

Birthday

Month

Day

Year

Multi-line address

Country/Region

Address

City

Zip / Postal code

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Name of School Attending or Attending

Graduation Date

Which Scenario applies to your situation?

1. Applicants who have failed the NCLEX three consecutive times will require a letter to begin the remedial course.

Applies

Does Not Apply

2. Applicants who do not hold an active license and have not practiced in the past five years, and are applying for licensure by endorsement based on having previously passed the State Board Test Pool Examination (SBTPE) or the NCLEX.

Applies

Does Not Apply

3. Applicants who passed the NCLEX more than five years ago and were not issued a license, would be required to complete an approved remedial course in order to be issued a license.

Applies

Does Not Apply

Other Scenario?

Is there any other information we need to know?