Application Process

Please fill out this form completely before clicking the print button.  Mail the completed form to the address at the bottom of this screen.

Note: this form is specifically for the Nursing Program. ADN applicants must also complete the Cloud County Community College Admissions form if they are not currently enrolled in other classes.

Fields marked in bold indicate required fields.

Title     Mr. Mrs. Ms. Miss Dr. Last Name First Name Middle Name Maiden or Previous Name Date of Birth (MM/DD/YYYY)
Street address City County State Zip Code
Permanent Phone Cell Phone E-mail Address
Please indicate entry level:
Applying to the Practical Nursing (PN) Level at NCKTC in Beloit.
Currently in a PN Program and wish to progress to the ADN (RN) Program.
An LPN and wish to progress to the ADN (RN) Level.

High school and college information:
High school attended High school city High school state Year of graduation
List all college (including high school concurrent enrollment), Universities, and Vocational-Technical Schools previously attended or currently attending:
College attended Location Degree / hours earned Year attended
College attended Location Degree / hours earned Year attended
College attended Location Degree / hours earned Year attended

To what other nursing programs are you applying?

   I certify that the above information is complete and correct to the best of my knowledge.

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Signature of applicant:

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After printing, please mail this form to:

Admissions Department
Cloud County Community College
2221 Campus Drive
Concordia, KS 66901