Central School of Practical Nursing

Graduate Questionnaire

First Name
Last Name
Address
City
State
ZIP
Email
Home Phone
Cell Phone
Work Phone
Class #
Are you presently employed as a nurse? yes no
Were you prepared for the practice of nursing, based on your education? yes no
If no, please explain

Current Place of Employment
Employment Start Date
Do you plan to continue your formal nursing education? yes no
If yes, when
Would you recommend our program to others? yes no
If no, please explain

Security Test
____ ____ _ _ ____ __ \|___ \ \| ___\| / \| / \ \| ___\| / /_ __) \| \|___ \ \| \| / _ \ \|___ \ \| '_ \ / __/ ___) \| \| \| / ___ \ ___) \| \| (_) \| \|_____\| \|____/ \|_\| /_/ \_\ \|____/ \___/ Please type the letters and numbers you see above in the field below: