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Enrollment Verification - Final_1_

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					                                       Nursing Education and Placement Program
                                               Funded by an ARRA U.S. Department of Labor Grant

                                                  Enrollment Verification
TO BE COMPLETED BY STUDENT:
Last Name: _______________________________ First Name: ___________________ Middle Initial: ____
Please complete the information below regarding the certificate or degree plan you are attending, then have a
school official complete the bottom section of the form.
   Institution: ______________________________________________________________________________
   Certification or Degree Program:                                                  Student ID:
         Enrollment status: Pending ____             Currently Enrolled ____              Hours Completed:
         Estimated graduation/completion date:
         Are you currently receiving any financial aid, scholarships or grants?                 Yes               No
            If yes, list financial aid, scholarships or grants type and amount:



TO BE COMPLETED BY SCHOOL OFFICIAL:
The student named above has been accepted for admission or is enrolled and in good standing:
Academic Year: ______________________ Institution:
Program in which student is accepted/enrolled:               CNA           LVN           ADN          ADN to BSN              BSN
Is the student considered full-time in the program?              Yes         No
First day of class for the academic semester:                                      Expected graduation Date: ____________
Is student in good academic standing? Yes                  No             Student’s current GPA: ___________________
Are there any current contingencies for the student’s acceptance or continued enrollment? Yes                            No
If “Yes” please describe:

Contact information for School of Nursing Official completing this form:
Name:                                                                     Title:
Phone number:                               Fax number:                             E-mail address:
I certify that the information provided on this Verification of Acceptance/Enrollment is accurate and complete to the best of my
knowledge and belief.


Signature of Nursing School Official                                                        Date:

                                                                                                       Coordinated by:
Please mail or fax completed form to:
Nursing Education and Placement Program
301 University Blvd - Galveston TX 77555-0909
Fax: 747-6720


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  OET&R 09/24/10                                                                       S:\DOL-NURSING-ED\Forms

				
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