Nursing Application Vocational Nursing Application Step 1 of 3 33% 2025-2026 RNEC Nursing ApplicationDo you currently have a LVN/PN license?*If you are a student who is currently in a LVN program and will receive their license by August 1st, check yes. No Yes Date* MM slash DD slash YYYY Name (As it appears on your Driver's License)* First Middle Last Maiden Social Security Number*Date of Birth* MM slash DD slash YYYY Other names known by:* First Last Ethnic Group*Select One White Black Hispanic Asian/Pacific Islander American Indian/Alaskan Prefer not to answer Home Phone*Cell Phone*Mailing Address* Street Address City State / Province / Region ZIP / Postal Code College Email Address* Personal Email Address* Do you authorize your doctor(s) to release your health records to this agency?* Yes No Emergency Contact* First Last Phone I certify that the above statements are true and correct. I authorize FPC and/or AC to investigate my personal history or work record if necessary. I understand that my eligibility is based on the results of the HESI test, background verification, and advising session interview.Signature of Applicant*Typing your name will replace a pen and ink signature. In the blanks below name the schools you have attended, their location, and the grades you completed. Include Other names you may have been registered as:High School and Grade Completed*College and Grade Completed*Other Schooling and Grade Completed*Have you ever attended any nursing program?* Yes No If yes, what type?Name and address of Nursing School attendedReason for withdrawalList your last two employers (including present). Give names, address, city, state and zip code.Name of Employer First Address Street Address City State / Province / Region ZIP / Postal Code Start Date of Employment MM slash DD slash YYYY End Date of Employment MM slash DD slash YYYY Job TitleEmployers Name First Address Street Address City State / Province / Region ZIP / Postal Code Start Date of Employment MM slash DD slash YYYY End Date of Employment MM slash DD slash YYYY Job TitlePlease list your clinical site choice. List your first three choices. If you do not select a site, one will be chosen for you. Choices are Borger, Dalhart, Dumas, Hereford, Pampa and Perryton*Please give the following information on courses you have completed:BIOL2401 - A & P I (REQUIRED COURSE) Grade Credit Hours Professor College where credit earned Please check one of the below fields if you do not have the course completed:* I have completed this course Currently enrolled in course I will take this course during the summer prior to admission BIOL2402 - A & P II (REQUIRED COURSE) Grade Credit Hours Professor College where credit earned Please check one of the below fields if you do not have the course completed:* I have completed this course Currently enrolled in course I will take this course during the summer prior to admission PSYC2301 - General Psychology (REQUIRED COURSE) Grade Credit Hours Professor College where credit earned Please check one of the below fields if you do not have the course completed:* I have completed this course Currently enrolled in course I will take this course during the summer prior to admission HITT1305 - Medical Terminology (REQUIRED COURSE) Grade Credit Hours Professor College where credit earned Please check one of the below fields if you do not have the course completed:* I have completed this course Currently enrolled in this course I will take this course during the summer prior to admission I will take this course during the program BIOL1322 - Elementary Nutrition (REQUIRED COURSE) Grade Credit Hours Professor College where credit earned Please check one of the below fields if you do not have the course completed:* I have completed this course Currently enrolled in this course I will take this course during the summer prior to admission I will take this course during the program MATH PN 0303 Math for Nursing Grade Credit Hours Professor College where credit earned Please check one of the below fields if you do not have the course completed: Currently enrolled in this course I will take this course during the summer prior to admission I do not plan to take this course Have you applied at Frank Phillips College Nursing Department before?* Yes No If Yes, list year:*Have you applied at Amarillo College Nursing Department before?* Yes No If Yes, list year:* The Board of Nursing looks at responses to questions relating to criminal conduct to determine eligibility for renewal. To check your eligibility for renewing your license, please review the following:1. Have you ever had any disciplinary action on a nursing license or a privilege to practice in any state, country, or province?* Yes No 2. Do you have an investigation or complaint pending on a nursing license or a privilege to practice in any state, country, or province?* Yes No 3. Have you, in the last 5 years*, been addicted to and/or treated for the use of alcohol or any other drug?* Yes No 4. For any criminal offense*, including those pending appeal, have you:You may only exclude Class C misdemeanor traffic violations or offenses previously disclosed to the Texas Board of Nursing on an initial or renewal application.Been arrested and have a pending criminal charge?* Yes No Been convicted of a misdemeanor?* Yes No Been convicted of a felony?* Yes No Pled nolo contendre, no contest, or guilty?* Yes No Received deferred adjudication?* Yes No Been placed on community supervision or court-ordered probation, whether or not adjudicated guilty?* Yes No Been sentenced to serve jail, prison time, or court-ordered confinement?* Yes No Been granted pre-trial diversion?* Yes No Been cited or charged with any violation of the law?* Yes No Been subject of a court-martial; Article 15 violation; or received any form of military judgment/punishment/action?* Yes No NOTE: Expunged and Sealed Offenses: While expunged or sealed offense, arrests, tickets, or citations need not be disclosed, it is your responsibility to ensure the offense, arrest, ticket or citation has, in fact, been expunged or sealed. It is recommended that you submit a copy of the Court Order expunging or sealing the record in question to our office with your application. Nondisclosure of relevant offenses raises questions related to truthfulness and character. (See 22 TAC §213.27)NOTE: Orders of Non-Disclosure: Pursuant to Tex. Gov't Code § 552.142(b), if you have criminal matters that are the subject of an order of non-disclosure you are not required to reveal those criminal matters. However, a criminal matter that is the subject of an order of non-disclosure may become a character and fitness issue. Pursuant to Gov't Code chapter 411, the Texas Nursing Board is entitled to access criminal history record information that is the subject of an order of non-disclosure. If the Board discovers a criminal matter that is the subject of an order of non-disclosure, even if you properly did not reveal that matter, the Board may require you to provide information about any conduct that raises issues of character and fitness.5. Have you ever had any licensing (other than a nursing license) or regulatory authority in any state, jurdisdiction, country, or province revoked, annulled, cancelled, accepted surrender of, suspended, placed on probation, refused to renew or otherwise discipline any other professional or occupational license, certificate, nurse aide registration or multistate privilege to practice that you held?* Yes No 6. Are you currently suffering from any condition for which you are not being appropriately treated that impairs your judgement or that would otherwise adversely affect your ability to practice nursing in a competent, ethical, and professional manner?* Yes No 7. *Are you currently the target or subject of a grand jury or governmental agency investigation?* Yes No 8. *Are you currently a participant in an alternative to discipline, diversion, or a peer assistance program? (This includes all confidential programs)*NOTE: Any positive response will remain confidential and not subject to public disclosure unless required by law. Yes No 9. Have you ever been granted the authority to practice nursing in any country, state, province, or territory?*NOTE: This does not apply to any nursing license(s) issued by another US state or territory, excluding Puerto Rico. If you were licensed in Puerto Rico, you should be answering yes. Yes No *Pursuant to the Texas Occupations Code §301.207, information, including diagnosis and treatment, regarding an individual's physical or mental condition, intemperate use of drugs or alcohol, or chemical dependency and information regarding an individual's criminal history is confidential to the same extent that information collected as part of an investigation is confidential under the Texas Occupations Code §301.466.If you answered "YES" to any of the questions listed above, attach a letter of explanation that is dated and signed indicating the circumstance(s) you are reporting to the Board.Attached Letter of Explanation (if required)Max. file size: 1 GB.
