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ADV Placement Application - Jones County Junior College

ADV Placement Application - Jones County Junior College

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List ALL colleges you have or are currently attending including JCJC:<br />

(Copies of each college transcript, including JCJC, must be attached to this application<br />

even if course work is shown on another college’s transcript.)<br />

(Institution/<strong>College</strong>)<br />

(Institution/<strong>College</strong>)<br />

Institution/<strong>College</strong>)<br />

(Dates Attended)<br />

(Dates Attended)<br />

(Dates Attended)<br />

Are you currently enrolled in Anatomy and Physiology I and II Fast Track? YES NO <br />

Have you earned any college degrees? YES NO If yes, list major:<br />

Which degree have you earned? AA or BS <br />

NOTE: The Mississippi Board of Nursing may, at its discretion, deny the application<br />

for licensure of any person who has been convicted of a criminal offense, under the provision<br />

of Title 97 of the Mississippi Code of 1972, as now amended, or any provision of this chapter.<br />

**Pursuant to Mississippi statue 43-11-13 health care workers must have a criminal<br />

background check. If you have any felonies or disqualifying events, your participation in<br />

clinical will be prohibited.<br />

Statement of Non-Discrimination<br />

<strong>Jones</strong> <strong>County</strong> <strong>Junior</strong> <strong>College</strong> does not discriminate on the basis of race, color, national origin, age, sex, or<br />

disability in its programs, activities, or employment practices. The following persons have been designated to<br />

handle inquiries and grievances regarding the non-discrimination policies: (ADA/ Section 504) Linda<br />

Abercrombie, ADA Coordinator, <strong>Jones</strong> <strong>County</strong> <strong>Junior</strong> <strong>College</strong>, 900 South Court Street, Ellisville, MS 39437,<br />

601-477-4149; (Title IX) John M. Carter, Title IX Coordinator, <strong>Jones</strong> <strong>County</strong> <strong>Junior</strong> <strong>College</strong>, 900 South Court<br />

Street, Ellisville, MS 39437, 601-477-4161.<br />

*Please note: Transcripts will NOT be forwarded from the admissions office to our<br />

department. Therefore, failure to have the ACT score, Nursing Entrance Test (TEAS® V)<br />

results, a copy of your current LPN license, employment verification letter, and ALL<br />

transcripts (including JCJC) ATTACHED TO YOUR NURSING PROGRAM APPLICATION will<br />

result in the application being ineligible for consideration for admission.<br />

Sex: (Check one) Male Female <br />

Race: (Check one) American Indian<br />

Asian<br />

Black/African American<br />

Hispanic<br />

Sex and race are used for statistical purposes only.<br />

White/Caucasian<br />

Multi-racial<br />

Other<br />

I have read the above and the information given is complete and truthful.<br />

Applicant Signature _______ Date ___

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