Nurses Foot Care Services Business Program Application

Please Print Name _____________________________________________________________
Address _____________________________________________________________________
City & State & Zip Code ________________________________________________________
Please Clearly Print Email Address _______________________________________________
Best Phone Number & Time Zone ________________________________________________

State(s) Licensed to Practice Registered Nursing in: _________________________________
License Number: _______________________________ Expiration Date: ________________

Dates you are interested in taking the program? _____________________________________

Have any of your nursing licenses ever been revoked or put on probation? Yes No
If so please explain: ____________________________________________________________
_____________________________________________________________________________

Please explain your community, geriatric, wound care, or diabetic nursing experience: ______________________________________________________________________________
______________________________________________________________________________

Are you a Nurse Educator ? Yes No
If so where?___________________________________________________________________

What other certifications do you have?______________________________________________

Are you already working in your own independent practice? Yes No
If so please describe it:___________________________________________________________
______________________________________________________________________________


Nurses Foot Care and Business Program Application

Please Print Name _____________________________________________________________ Address _____________________________________________________________________ City & State & Zip Code ________________________________________________________ Please Clearly Print Email Address _______________________________________________ Best Phone Number & Time Zone ________________________________________________ State(s) Licensed to Practice Registered Nursing in: _________________________________ License Number: _______________________________ Expiration Date: ________________ Dates you are interested in taking the program? _____________________________________ Have any of your nursing licenses ever been revoked or put on probation? Yes No If so please explain: ____________________________________________________________ _____________________________________________________________________________ Please explain your community, geriatric, wound care, or diabetic nursing experience: ______________________________________________________________________________ ______________________________________________________________________________ Are you a CNS, NP , or APN or currently in such a program? Yes No Are you a Nurse Educator ? Yes No If so where?___________________________________________________________________ What other certifications do you have?______________________________________________ Does your state allow RN's to work in independent practices? Yes No Are you already working in your own independent practice? Yes No If so please describe it:___________________________________________________________ ______________________________________________________________________________
I have enclosed a check for $595 and understand this fee is only reimbursable up to 1 month prior to the program. It may be applicable to a program at a later date if openings exist. I have also enclosed a copy of my nursing license, driver's license, and Proof of Independent Professional Liability Insurance - which I understand will be verified against my driver's license at the beginning of the program. Signed _________________________________________________Date___________ Please send this completed application, check, & documentation to the address below. Thank you! NFCS Associates Services, LLC 3588 Plymouth Road PMB#221 Ann Arbor, MI 48105-2603
Copyrights 1998-2012 ~ NFCS Associates Services LLC ~ All Rights Reserved Ann Arbor, Michigan 48105-2603 Disclaimer(s)