New England Schools of Practical Nursing and Allied Health
Divisions of HEALTH CAREER TRAINING ASSOCIATES, LLC
60 Rogers Street
Manchester, NH 03103
603 622-8400
STUDENT APPLICATION
PLEASE PRINT IN INK.
*Your answer to these questions is optional. They are useful to us for statistical purposes & educational planning.
Last Name ____________________________First Name________________________________MI_____
Address________________________________________ E mail__________________________________
City ___________________________________________State __________Zip_____________________
(H) Phone Number ___________________________(C) Phone Number___________________________
*Date of birth_____/______/______ Social Security Number ____________________________
Will you be receiving funding through an agency ? Yes_____ No_____
If Yes, Which agency? ________________________________________________________________
Contact Person _____________________________________________________________________
Are you a U.S. Citizen? _____Yes _____No If No, what is your immigration status__________________
*Language other than English (spoken or written):_______________________________________
*Your Country of Origin ______________________________________________________
Please circle the highest level of education you have completed:
6 7 8 9 10 11 12 GED Year:__________
College-Post grad Other post-secondary education? _____________________________
When do you anticipate entering a program? ____________ Year_________ Day_____ Evening_____
Which program are you applying to?_____________________________________________
Emergency Contact Person:
Last Name _____________________________First name___________________________
Relationship_______________Address__________________________________________
City____________________________State___________________ZipCode___________
(H) Phone number_________________________(W) Phone__________________________
==========================================================================
The information provided on this application is considered to be confidential. Health Career Training Associates reserves the right to
deny admission to any applicant who does not possess the adequate skills needed for a reasonable chance of success in his/her
chosen program.
I certify that I have read and understand the above statement. I certify that the above information that I have provided is complete and
true. If accepted, I agree to abide by the student policies as noted in the Student Handbook.
Applicant Signature_______________________________________________Date__________________
*Your answer to these questions is optional. They are useful to us for statistical purposes & educational planning and will not be
shared with anyone without your permission
Mail Application with $150.00 fee to: Health Career Training Associates
Make check payable to HCTA 60 Rogers Street Manchester, NH 03103
Do Not Write below this line
----------------------------------------------------------------------------------------------------------------------------------------------------------------------
OFFICE USE ONLY: ROUTING
Posted Date________ Receipt sent $_______Paid Check #_______ Credit Card______ Agency Auth. _________