Registration – RN/LPN NCLEX Assistance

RN/LPN NCLEX ASSISTANCE - REGISTRATION FORM

Personal Information Full Name (Printed) * Username * First Name * Middle Name Last Name * Suffix Name (e.g., Jr., Sr.) Birth Date * Place of Birth * Age * Email * Password * Marital Status * Mother's Maiden Name *

Contact Information Address * Address 2 Town/City * Province/State * Zip Code * Country * Phone Number * Mobile Number *

Elementary Education Elementary School * From (mm/dd/yyyy) * To (mm/dd/yyyy) * Elementary School Address * Elementary School Telephone Number *

High School Education High School * High School Address * High School Telephone Number * From (mm/dd/yyyy) * To (mm/dd/yyyy) *

Senior High School Education Senior High School * Senior High School Address * From (mm/dd/yyyy) * To (mm/dd/yyyy) *

College Education and Professional Info School of Nursing * College Address * College Telephone Number * From (mm/dd/yyyy) * To (mm/dd/yyyy) * PRC License State Board of Nursing * Expiration of Application *

Payment Information Payment Method *

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