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NCLEX USA Assessment

Instruction: Kindly fill out all the information needed. Please be sure to complete every field.


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I. Write you exactly as it appears in the following:


Passport

Nursing License

Nursing Diploma

Single Name if married (for women)

Married Name



II. Fill out the following details:


Fb Name
Email
Birth Date
Gender
Male Female

Ethnicity
Status
SSN

Mobile #
Overseas Mobile #
Mother's Maiden Name



III. Security Question:


Question #1
Question #2
Question #3

Answer #1

Answer #2

Answer #3



IV. Complete mailing address:


House #/Unit #
Floor & Building
Street

Block and Lot
Brgy./Village
City/Municipality

State/Province
Zip code



V. If you ever taken the SBPT, NCLEX or state-constructed examination for license as either a Registered Professional Nurse or a License Practical Nurse:


State or Territory
Profession
Date of examination

Exam Name
License number(if granted)

I. Elementary School

Name of Elementary School
City/Municipality
State/Province
Country
Number of years attended
Month and year started
Month and year completed



Please Indicate any futher schools here:

Name of Elementary School
City/Municipality
State/Province
Country
Number of years attended
Month and year started
Month and year completed



II. High School:

Name of High School
City/Municipality
State/Province
Country
Number of years attended
Month and year started
Month and year completed



Please Indicate any futher schools here:

Name of High School
City/Municipality
State/Province
Country
Number of years attended
Month and year started
Month and year completed



III. Nursing School:

Name of Nursing School
City/Municipality
State/Province
Country
Number of years attended
Month and year started
Month and year completed



Please Indicate any futher schools here:

Name of Nursing School
City/Municipality
State/Province
Country
Number of years attended
Month and year started
Month and year completed

I. Exam History(Previous NCLEX Exam):

State
Date of Exam
Type of Exam
NCLEX RN
NCLEX PN



II. Please provide an answer to the following query

How many times have you taken the NCLEX?
State you want to apply for



III. Do you have an existing online account to the state you want to apply? If so, kindly state the login information.

Email
Password



IV. Do you have an existing Pearson Vue account? If so, kindly state the login information.

Email
Password

I. Requirements(Clear Scanned Copy)

Please ensure that you submit clear, SCANNED copies of your documents. They should be in either PDF or image format and should not be cropped or altered. Each document should be saved as a separate file.
Note:
Rename your file and do not use coma (,) and Ñ
Example: TOR_REYES.pdf
No dragging of files when uploading requirements

You may prepare the following:
📌Updated Passport with signature
📌Transcipt of Record
📌Nursing Diploma
📌PSA Birth Certificate
📌Marriage Certificate (applicable for female only)
📌Updated PRC ID(front and back in one page)
📌Board rating
📌2x2 Passport size photo
📌RLE

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Agreement


I declare that I have personally accomplished this Applicant form my Personal details which is true and correct. I authorized the agency head / authorized representative to verify / validate the contents stated herein. Any misleading or inaccurate matters included in this form shall serve as concrete ground for invalidity of my application.
Full Name
Date Today