Now is a great time to consider a career in healthcare. Please enable JavaScript in your browser to complete this form.Applicant Information**It is the applicant’s or student’s responsibility to contact the school, if your contact information changes.**Which Program Do You Wish to Apply To? *- (Choose program of interest here) - Practical Nursing Program (LPN)Registered Nursing Program (RN)Name (Last, First, Middle I) *Preferred NameMaiden or Former Name:Social Security Number *Date of Birth *Gender *MaleFemaleStreet Address *City *State *Zip *County *Drivers License #Home Phone Number *Cell Phone NumberEmail *Marital Status *MarriedSingleU.S. Citizen *YesNoResident AlienVisa TypeEthnic Heritage (Optional)African American/BlackAsian/Pacific IslanderHispanicAmerican IndianCaucasian/WhiteHave You Ever Been Convicted of a Felony?NoYesHealthcare Worker LicenseDo You Have Any Healthcare Worker Licenses?STNALPNCPROtherPlease chsck all that applyOther LicenseSTNA License NumberSTNA StateSTNA Expiration DateLPN License NumberLPN StateLPN Expiration DateCPR Company of CertificationCPR Expiration DateOther License NumberOther StateOther Expiration DateBackground Information: Have you ever been arrested or convicted for any crime (unless it was expunged)? *YesNo If Yes, please explain:Academic HistoryPlease fill in the following info about your high school or GED. *GEDHigh SchoolGraduation Date *GED CityGED StateGED YearHigh School NameHigh School CityHigh School StatePreviously Attended OIAH?Name when attendedHave you ever been dismissed, disciplined or placed on probation from a college or university? (If yes, please explain.)Please list all colleges and universities you have attended.CityStateDegree/MajorDates AttendedGraduatedYesNoSchool Name CityStateDegree/MajorDates AttendedGraduatedYesNoIf you previously attended a similar program but did not complete, please indicate the reason for leaving.EmploymentList your current job followed by any job you have held for six months or longer within the last five years.Current EmployerJob TitlePhoneDates EmployedResponsibilitiesWe are located at 6245 Old Troy Pike, Huber Heights, OH,45424 | oiah.edu | phone: 937-237-1010 | fax: 937-237-0506 | Oh. Reg. #10-03-1924T OIAH admits students of any race, color, sex, and national or ethnic origin. OIAH is a non-profit 501(c)(3) organization.EmailAPPLY
