Prometric Applicant Form

1) Personal Information

* Indicates required field

Name: *

Date of Birth: *

Birth Country: *

Birth State/Province: *

Nationality: *

Country of Citizenship: *

Gender: *

Male Femal

Religion: *

Marital Status: *

Single Married Divorced Widowed

Marital Status (If married, please provide name before marriage): *

Residential Address: *

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City

State

Zip Code

Country

Mailing Address (if different from residential address): *

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State

Zip Code

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Email Address: *

Phone Number: *

Passport Number: *

Passport Expiration Date: *

Other National Identification Number: *

Other National Identification Expiration Date: *

2) Educational Background

List of 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: *

School Address: *

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City

State

Zip Code

Country

Number of Years Attended: *

Attendance Date (from month/day/year to month/day/year): *

Graduation Date (month/day/year): *

1b. Name of Elementary School Attended (Write N/A if you attended only one school): *

School Address: *

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City

State

Zip Code

Country

Number of Years Attended: *

Attendance Date (from month/day/year to month/day/year): *

Graduation Date (month/day/year): *

2a. Name of High School Attended: *

School Address: *

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City

State

Zip Code

Country

Number of Years Attended: *

Attendance Date (from month/day/year to month/day/year): *

Graduation Date (month/day/year): *

2b. Name of High School Attended (Write N/A if you attended only one high school): *

School Address: *

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City

State

Zip Code

Country

Number of Years Attended: *

Attendance Date (from month/day/year to month/day/year): *

Graduation Date (month/day/year): *

3. Name of Nursing School Attended: *

Degree Granted: *

School Address: *

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City

State

Zip Code

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Number of Years Attended: *

Attendance Date (from month/day/year to month/day/year): *

Graduation Date (month/day/year): *

Other Post Secondary Schools or Colleges Attended: *

4. Name of School(Write N/A if you attended only one college or university): *

Major or Degree: *

School Address: *

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City

State

Zip Code

Country

Number of Years Attended: *

Attendance Date (from month/day/year to month/day/year): *

Graduation Date (month/day/year): *

3) INFORMATION ABOUT NURSE LICENSE

1. Professional Title: *

Issuing Agency: *

Address of Issuing Agency: *

Date License Issued: *

License Number: *

Limitations On License/ Certificate (if any): *

Expiration Date of License: *

2. Professional Title: *

Issuing Agency: *

Address of Issuing Agency: *

Date License Issued: *

License Number: *

Limitations On License/ Certificate (if any): *

Expiration Date of License: *

4) 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 &/or communicated to our application processors.

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