Student Intake Sheet

Student Intake Sheet

Welcome to PITC!

Today's Date

Program intersted In:

Day and Evening

Full Name

Full Street Address

City

zip code

State

Telephone#

Email address

Date of Birth

SSN

Citizenship

Green Card/Alien #

High School Name

Name Used

Year of Graduation

Emergency Contact Information:

Contact Name

Relationship

Contact Number

High School Diploma or Transcript or GED submitted:

YesNo

Foreign Evaluation Completed:

YesNo

If yes, then please submit the foreign evaluation to an Admissions Representative.

Proof of Vaccination submitted:

YesNo

Have you previously attended another college or university?

YesNo

SUBMIT

Practical Nurse

Associate in Specialized Technology Degree Program

Day Class : Monday- Friday from 8:30 am to 2:00 pm

Evening Class : Monday- Thursday 6:00 pm to 10:00 pm

Please fill out the form below to schedule a time to meet with our admissions advisors. In addition you can Call Now [(267) 754-7024](tel:+12677547024) or email your questions to: [bray@pitc.edu](mailto:info@pitc.edu)

Fill out the form below, and we will be in touch shortly.

Contact Information

Name

email

phone

Applied For

Clinical InstructorNutrition InstructorInstructor of Anatomy and Physiology (A&P)​Pharmacology InstructorNursing Instructor

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