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1) Personal Background
*
Indicates required field
Name:
*
As it appears exactly on a government issued ID that you intend to take on the NCLEX Exam e.g. passport, US permanentresidence card, US driver’s license
Date of Birth:
*
Birth Country
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Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antartica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina and Faso
Burma
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Zealand
Nicaragua
Niger
Nigeria
North Korea
Norway
Oman
Pakistan
Palau
Palestinian Territories
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
Birth State/Province:
*
Native Language:
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Afar
Afrikaans
Aja-Gbe
Akan
Albanian
Amazigh
Amharic
Anii
Arabic
Armenian
Assamese
Aymara
Azerbaijani
Balanta
Bambara
Bariba
Bassari
Bedik
Belarusian
Bengali
Berber
Biali
Bislama
Boko
Bomu
Bosnian
Bozo
Buduma
Bulgarian
Burmese
Cantonese
Catalan
Chinese, Mandarin
Chichewa
Chirbawe
Chokwe
Comorian
Croatian
Czech
Dagaare
Dagbani
Dangme
Danish
Dari
Dendi
Dhivehi
Dioula
Dioula
Dutch
Dzongkha
English
Estonian
Ewe-Gbe
Fijian
Filipino
Finnish
Fon-Gbe
Foodo
French
Fula
Ga
Gbe
Gen-Gbe
Georgian
German
Gonja
Gourmanché
Greek
Guaraní
Gujarati
Haitian Creole
Hassaniya
Hausa
Hebrew
Hindi
Hiri Motu
Hungarian
Igbo
Icelandic
Indonesian
Irish
Italian
Japanese
Jola
Kabye
Kalanga
Kanuri
Kasem
Kazakh
Khmer
Kikongo-Kituba
Kimbundu
Kinyarwanda
Kirundi
Kissi
Khoisan
Korean
Kpelle
Kurdish
Kwanyama
Kyrgyz
Lao
Latin
Latvian
Lingala
Lithuanian
Lukpa
Luxembourgish
Macedonian
Malagasy
Malay
Malinke
Maltese
Mamara
Manding
Mandinka
Mandjak
Mankanya
Manx Gaelic
Māori
Marshallese
Mbelime
Moldovan
Mongolian
Montenegrin
Mossi
Nambya
Nateni
Nauruan
Ndau
Ndebele
Nepali
New Zealand Sign Language
Noon
North Korean
Northern Sotho
Norwegian
Nzema
Oniyan
Ossetian
Palauan
Papiamento
Pashto
Persian
Polish
Portuguese
Quechua
Romanian
Romansh
Russian
Safen
Samoa
Sango
Sena
Serbian
Serer
Seychellois Creole
Shona
Sinhala
Slovak
Slovene
Somali
Songhay-Zarma
Soninke
Sotho
Spanish
Susu
Swahili
Swati
Swedish
Syenara
Tajik
Tamasheq
Tamil
Tammari
Tasawaq
Tebu
Tetum
Thai
Tigrinya
Tok Pisin
Toma
Tonga
Tongan
Tshiluba
Tsonga
Tswana
Turkish
Turkmen
Tuvaluan
Ukrainian
Umbundu
Urdu
Uzbek
Venda
Vietnamese
Waama
Waci-Gbe
Wamey
Welsh
Wolof
Xhosa
Xwela-Gbe
Yobe
Yom
Yoruba
Zimbabwean sign language
Zulu
Country of Citizenship:
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Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burma
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Zealand
Nicaragua
Niger
Nigeria
North Korea
Norway
Oman
Pakistan
Palau
Palestinian Territories
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
Religion
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Gender:
*
Male
Female
Marital Status:
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Single
Married
Divorced
Widowed
Marital Status (If married, please provide name before marriage):
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Residential Address:
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Mailing Address (if different from residential address):
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Email Address:
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Phone Number:
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Do you require special accommodations for a disability? (Yes or No)
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Yes
No
Have you ever been charged or convicted of felony or misdemeanor?
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Yes
No
Have you ever taken the SBTP or NCLEX or CGFNS exam?
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Yes
No
Have you ever taken the SBTP or NCLEX or CGFNS exam? (If yes, specify what exam, date and location)
*
Have you ever taken the SBTP or NCLEX or CGFNS exam? (If yes, specify what exam, date and location)
*
Yes
No
Have you previously applied to CGFNS? (If yes, please provide CGFNS ID number)
*
Have you ever taken any English Competency Exam like TOEFL, IELTS, etc.?
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Yes
No
Have you ever taken any English Competency Exam like TOEFL, IELTS, etc.? (If yes, provide the name of Exam, scores and date taken)
*
Intended U.S. State Practice
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
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
2) Educational Background
"Please list all schools attended, whether or not you completed the course. Attach additional sheets if necessary, to list
more schools attended."
1a. Name of Elementary School Attended
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School Address & Zip Code
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Number of Years Attended
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Attendance Date (MM/DD/YYYY to MM/DD/YYYY)
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Graduation Date (MM/DD/YYYY)
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1b. Name of Elementary School Attended (Write N/A if you attended only one school)
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School Address & Zip Code
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Number of Years Attended
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Attendance Date (MM/DD/YYYY to MM/DD/YYYY)
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Graduation Date (MM/DD/YYYY)
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2a. Name of High School Attended
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School Address & Zip Code
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Number of Years Attended
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Attendance Date (MM/DD/YYYY to MM/DD/YYYY)
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Graduation Date (MM/DD/YYYY)
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2b. Name of High School Attended (Write N/A if you attended only one high school)
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School Address & Zip Code
*
Number of Years Attended
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Attendance Date (MM/DD/YYYY to MM/DD/YYYY)
*
Graduation Date (MM/DD/YYYY)
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3. Name of Nursing School Attended
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Degree Granted
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School Address & Zip Code
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Number of Years Attended
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Attendance Date (MM/DD/YYYY to MM/DD/YYYY)
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Graduation Date (MM/DD/YYYY)
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Other Postsecondary Schools or Colleges Attended
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4. Name of School(Write N/A if you attended only one college or university)
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Major or Degree
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School Address & Zip Code
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Number of Years Attended
*
Attendance Date (MM/DD/YYYY to MM/DD/YYYY)
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Graduation Date (MM/DD/YYYY)
*
3) Recent Work Experience
Country
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Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burma
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curacao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Zealand
Nicaragua
Niger
Nigeria
North Korea
Norway
Oman
Pakistan
Palau
Palestinian Territories
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
City/State/Province
*
Address
*
Profession
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Number of Years
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1
2
4
5
6
7
8
9
10
11
12
13
14
15
16
4) Information about Nurse License
Profession
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Registered Nurse
Practical Nurse
Vocational Nurse
Volunteer Nurse
Midwife
Issuing Agency
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Address of Issuing Agency
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Line 1
Line 2
City
State
Zip Code
Country
Date License Issued
*
License Number
*
Limitations On License/ Certificate (if any)
*
Expiration Date of License
*
2. Professional Title
*
Issuing Agency
*
Address of Issuing Agency
*
Line 1
Line 2
City
State
Zip Code
Country
Date License Issued
*
License Number
*
Limitations On License/ Certificate (if any)
*
Expiration Date of License
*
5) Agreement
All applications are to be paid in the same day the application is submitted.
All applications must be accompanied by authorized credit card payment using our Credit Card Authorization Form
By submitting this application, you authorize
ApplyReady.com
to begin application process once payment is completed.
Cancellation can only be entertained if the application process has not been initiated and/or communicated to our application processors.
6) Other Important Information
US Immigration Status (Write N/A if not residing in the US)
*
Social Security Number (Write N/A if you do not have a US Social Security Number)
*
USCIS or Alien Registration Number (Write N/A if you do not have a USCIS Number)
*
When do you plan to take the NCLEX?
*
In what location do you plan to take the NCLEX Exam?
*
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