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Apply
Ready to Apply
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Practical Nursing Program Application
Practical Nursing Program Application
Students must first apply and be accepted to New River CTC before applying to the Practical Nursing Program.
Please note that new application materials must be submitted each time a student applies to the Practical Nursing Program.
Date of Application
(Required)
Month
Day
Year
Name
(Required)
First
Middle
Last
List any former last name(s) you have used for work or school:
Mailing Address
(Required)
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Please list street or PO Box where you receive your mail
Phone
(Required)
Please provide the best number for us to contact you
New River CTC Student ID Number
Practical nursing program applicants must first apply to New River CTC prior to applying to the Practical Nursing Program
Email
(Required)
New River CTC email or personal email address
Preferred method of contact
(Required)
Email
Mail
Phone
Please check that the contact information that you have listed for your preferred method is accurate
Cohort you wish to apply for
(Required)
Greenbrier Valley Campus, Lewisburg
Nicholas County Campus, Summersville
Raleigh County Campus, Beaver
Summers County ARH Hospital, Hinton
Emergency Contact
Emergency Contact Name
(Required)
First
Last
Emergency Contact Phone
(Required)
Emergency Contact Relationship
(Required)
Educational Background
High School
High School Address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Graduation Date
Month
Day
Year
College
College Address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Graduation Date
Month
Day
Year
Have you attended any other nursing programs?
(Required)
Yes
No
Nursing Program
Date Attended
Month
Day
Year
Nursing Program Address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Most Recent Work Experience
Employer
Employer Address
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Dates of Employment
Reason for Leaving
Background
Please list all previous healthcare experience
(Required)
Have you ever been convicted of a felony or do you have any felony charge(s) pending against you at this time?
(Required)
Yes
No
Have you ever been convicted of a misdemeanor?
(Required)
Yes
No
Failure to disclose any misdemeanor or felony charges may result in rejection of your practical nursing program application.
Please write 200-300 words about why you are interested in a career in nursing and why you would like to receive your training through New River CTC's Practical Nursing Program.
(Required)
Signature
(Required)
By electronically signing and submitting this form, I declare that the information I have supplied on this application is complete, truthful, and correct. I further authorize New River Community and Technical College personnel to verify the information given on this application. I understand that omitting previous college information and/or providing false information may lead to dismissal.
New River CTC does not discriminate in its educational programs or in admission to, access to, treatment in, or employment on the basis of race, color, religion, sex (including pregnancy), sexual orientation, gender identity, national origin, age, marital status, veteran or military status, disability, or genetic information or any other status or condition protected by applicable federal or state laws. The following office has been designated to handle inquiries regarding the College’s non-discrimination policies relating to disabilities, sex, Title IX or other forms of discrimination: Peter Hoeman, Dean of Student Affairs and Title IX Coordinator, 304-929-5027, phoeman@newriver.edu 280 University Drive Beaver, WV 25801 Additional information can be found on the College’s website at www.newriver.edu/nondiscrimination.
Date Last Modified:
June 10, 2022
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