Select *Program of InterestBACHELOR OF SCIENCE IN NURSING DEGREE (RN to BSN)ASSOCIATE OF SCIENCE IN NURSING DEGREE (RN)PRACTICAL NURSING (LPN)RN-PN REMEDIALPATIENT CARE TECHNICIAN (HHA, CNA, PCA, EKG & PHLEBOTOMY)Desired Date *How did you hear about PBC? *How did you hear about PBC?Career SourceCollege Fair BoyntonInternetOtherReceptionReferralWalk inYou will be asked to pay your $150.00 Application Fee after submission of your applicationFirst Name (as it appears on your government issued ID) *Middle Name (as it appears on your government issued ID) *Last Name (as it appears on your government issued ID) *Name(s) by which you have been known in the pastEmail Address *HTMLPhysical Address & Phone Number(s)PhoneStreet Address *Apartment, suite, etcCity *State/Province *ZIP / Postal Code *Country *AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaAustraliaArubaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCabo VerdeCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGuernseyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauNorth MacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontserratMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSaint HelenaSaint Pierre & MiquelonSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSpainSri LankaStateless PersonsSudanSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUS Minor Outlying IslandsUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemenZambiaZimbabweMailing AddressStreet Address *Apartment, suite, etcCity *State/Province *ZIP / Postal Code *Country *AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaAustraliaArubaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCabo VerdeCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGuernseyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauNorth MacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontserratMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSaint HelenaSaint Pierre & MiquelonSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSpainSri LankaStateless PersonsSudanSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUS Minor Outlying IslandsUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemenZambiaZimbabweDate of Birth *Citizenship Status *Citizenship StatusNon-Resident AlienResident AlienUS CitizenSocial Security Number *Are you a United States Veteran? *Gender *GenderMaleFemaleUnknownPlace of Birth *Place of BirthUNITED STATESCANADAAFGHANISTANALBANIAALGERIAANDORRAANGOLAANTIGUAARGENTINAARMENIAARUBAAUSTRALIAAUSTRIAAZERBAIJANBAHAMASBAHRAINBANGLADESHBARBADOSBELARUSBELGIUMBELIZEBENINBERMUDABHUTANBOLIVIABOSNIABOTSWANABRAZILBRUNEIBULGARIABURKINA FASOBURMABURUNDICAMBODIACAMEROONCAPE VERDECENTRAL AFRICAN REPUBLICCEYLONCHADCHILECHINACOLOMBIACOMOROSCONGOCOSTA RICACROATIACUBACYPRUSCZECH REPUBLICDENMARKDJIOUTIDOMINICADOMINICAN REPUBLICECUADOREGYPTEL SALVADORENGLANDEQUATORIAL GUINEAERITREAESTONIAETHIOPIAFIJIFINLANDFRANCEFRENCH ANTILLESFRENCH GUIANAGABONGAMBIAGEORGIAGERMANYGHANAGREECEGRENADAGUADELOUPEGUATEMALAGUINEAGUINEA-BISSAUGUYANAHAITIHOLY SEEHONDURASHONG KONGHUNGARYICELANDINDIAINDONESIAIRANIRAQIRELANDISRAELITALYIVORY COASTJAMAICAJAPANJORDANKAZAKHSTANKENYAKIRIBATIKOREAKUWAITKYRGZSTANLAOSLATVIALEBANONLESOTHOLIBERIALIBYALIECHTENSTEINLITHUANIALUXEMBOURGMACAUMACEDONIAMADAGASCARMALAWIMALAYSIAMALDIVESMALIMALTAMARSHALL ISLANDSMARTINIQUEMAURITANIAMAURITIUSMEXICOMICRONESIAMOLDOVAMONACOMONGOLIAMOROCCOMOZAMBIQUEMYANMARNAMIBIANAURUNEPALNETHERLANDSNETHERLANDS ANTILLESNEW ZEALANDNICARAGUANIGERNIGERIANORTH KOREANORTHERN IRELANDNORWAYOMANPAKISTANPALAUPANAMAPAPUA NEW GUINEAPARAGUAYPERUPHILIPPINESPOLANDPORTUGALPRINCIPEQATARREPUBLIC OF CHINAROMANIARUSSIARWANDASAN MARINOSAO TOMESAUDI ARABIASCOTLANDSENEGALSERBIASEYCHELLESSIERRA LEONSINGAPORESLOVAKIASLOVENIASOLOMON ISLANDSSOMALIASOUTH AFRICASOUTH KOREASOUTH-WEST AFRICASPAINSRI LANKAST. KITTSST. LUCIAST. NEVISST. VINCENTSUDANSURINAMESWAZILANDSWEDENSWITZERLANDSYRIATAIWANTAJIKSTANTANZANIATHAILANDTHE GRENADINESTOBAGOTOGOTONGATRINIDADTUNISIATURKEYTURKMENISTANTUVALUUAEUGANDAUKRAINEUNITED KINGDOMUPPER VOLTAURUGUAYUZBEKISTANVANUATUVATICAN CITYVENEZUELAVIETNAMWALESWEST AFRICAWEST INDIESWESTERN SAMOAYEMENZAIREZAMBIAZIMBABWEMarital Status *Marital StatusClergyDivorced/SeperatedMarriedSingleUnknownWidowedAre you Hispanic or Latino? *Are you Hispanic or Latino?YesNoSelect one or more of the following races:WhiteBlack or African AmericanAsianAmerican Indian or Alaska NativeHawaiian or Other Pacific IslanderHTMLSection 456.0635., Florida StatutesImportant Notice for Initial Licensure Applicants and Renewals: Effective July 1,2012, Section 456.0635, Florida Statutes, provides that health care boards or the department shall refuse to issue a license, certificate or registration and shall refuse to admit a candidate for examination if the applicant: (2) Each board within the jurisdiction of the department, or the department if there is no board, shall refuse to admit a candidate to any examination and refuse to issue a license, certificate, or registration to any applicant if the candidate or applicant or any principal, officer, agent, managing employee, or affiliated person of the applicant. (a) Has been convicted of, or entered a plea of guilty or nolo contendere to, regardless of adjudication, a felony under chapter 409, chapter 817, or chapter 893, or similar felony offense committed in another state or jurisdiction, unless the candidate or applicant has successfully completed and drug court program for that felony and provides proof that the plea has been withdraw or the charges have been dismissed. Any such conviction or plea shall exclude the applicant or candidate from licensure, examination, certification, certification, or registration unless the sentence and any subsequent period of probation for such conviction or plea ended. 1. For felonies of the first or second degree, more than 15 years before the date of application. 2. For felonies of the third degree, more than 10 years before the date of application, except for felonies of the third degree under s. 893.13 (6)(a). 3. For felonies of the third degree under s. 893.13 (6)(a), more than 5 years before the date of application, (b) Has been convicted of, or entered a plea of guilty or nolo contendere to, regardless of adjudication, a felony under 21 U.S.C. ss. 801-970, or 42 U.S.C. ss. 1395-1396, unless the sentence and any subsequent period of probation for such conviction or plea ended more than 15 years before the date of the application; (c) Has been terminated for cause from the Florida Medicaid program pursuant to s. 409.913, unless the candidate or applicant has been in good standing with the Florida Medicaid program for the most recent 5 years; (d) Has been terminated for cause, pursuant to the appeals procedures established by the state, from any other state Medicaid program, unless the candidate or applicant has been in good standing with the state Medicaid program for the most recent 5 years and the termination occurred at least 20 years before the date of the application; or (e) Is currently listed on the United State Department of Health and Human Services Office of Inspector General’s List of Excluded Individual and Entities. NOTE: This section does not apply to candidates or applicants for initial licensure or certification who were enrolled in an educational or training program on or before July 1, 2009, which was recognized by a board or, if there is no board, recognized by the department, and who applied for licensure after July 1, 2012.Check this box if convicted of, or entered a plea of guilty, nolo contendre, or no contest to any crime in any jurisdiction other than a minor traffic offense:Please check this box if you have ever been denied or is there now a proceeding to deny your application for ANY healthcare license to practice in Florida or any other stat, jurisdiction or country:Check the box if you had an investigation or disciplinary action takes against your license to practice ANY healthcare related profession by a licensing authority in any state, jurisdiction or countryCheck the box if you have ever surrendered a license to practice any healthcare related profession in any state, jurisdiction or country while such disciplinary charges were pending against you:Check this box if you are a current LVN/LPN/Psych TechCheck this box if you are a ChiropractorCheck this box if you are a foreign medical doctorIf you currently hold an active healthcare provider license in Florida or any other state, please provide 1) License type, 2) License Number, 3) State Issued, 4) Expiration DateAny statement made on this application that is false and known to be false by the applicant at the time of making such statement shall be deemed fraudulent and my subject the applicant for disciplinary proceedings.Admission to any nursing program may be denied based on the results of the criminal background check drug screening, and /or previous academic history, behavior. You agree to submit to consumer credit reports, as needed, for financial and purposes. All students entering nursing core concentration course must have on file a current American Heart Association Healthcare Provider CPR certification that is outlined in the School Of Nursing Handbook. All students must submit documentations and proof of immunity for Hepatitis Be; Varicella; Measles, Mumps, and Rubella. Students are required to have season flu and current Tetanus, Diphtheria, and Pertussis vaccination; and Tuberculosis screening. A health physical must also be submitted. For Additional information regarding health requirements and documentation please refer to the School of Nursing Handbook and Catalog. These requirements are subject to change without notice. Students are financially responsible to meet current and required health requirements. All students must have a cleared background and negative drug screen through Certified Background. For further details please refer to the School of Nursing Student Handbook and Catalog. Please read each statement below: 1) I understand that it is my responsibility to familiarize myself with the School of Nursing and Graduate Studies Handbook and College Catalog. 2) I am aware of the practicum/ clinical requirements outlined in the College Catalog and School of Nursing and Graduate Studies handbook and I can fulfill the requirements. 3) I am aware that clinical hours may be scheduled for evenings, overnight, weekends, and holidays. The College may not be able to accommodate special clinical schedule requests. 4) I am aware of the physical and mental capabilities outlines on the Functional Health and Abilities form and I attest that I am able to meet these requirements. 5) I am aware if there is a change to my physical and / or mental health capabilities outlined on the functional health and abilities form that will affect my ability to meet the requirements as a student, I will notify the Dean of Nursing within 24 hours. 6) I am aware of the admission requirements as outlined in the College Catalog and understand that all requirements must be met for admission consideration. 7) I am aware curriculum modifications or changes may occur to include policies and procedures during my enrollment. 8) I am aware of the nursing programs current program outcomes. The current licensure pass rate can be reviewed at https://appsmqa.doh.state.fl.us/MQASearchServices/Home. I certify that the information I have provided on this application is the true and accurate. I have read and understand the application and Catalog which is available at pbccedu.com. I have read each statement and attest that I am aware and agree with each statement.I certify that the information I have provided on this application is the true and accurate. I have read each statement and attest that I am aware and agree with each statement.Please type your full name and today's date: *Send Message