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Registration Form

Last, First Name
Address
City	State Zip Code
Telephone	Cell
FAX

Level:

LPN  RN

                           Level ADN  BSN   Today's Date:

How did you hear about the class? Date of graduation

Name of school you attended

Date of upcoming NCLEX exam

Number of times you took the exam before

*E-mail address

Cont.

 Requested Schedule

Please select 10 days and times from below - 5 out of ten  will be chosen. You will be notified with 48 hours of receipt of your request. You will have a maximum of 30 days to complete your review from the initial date selected by RTP staff.

Monday through Saturday / Times 8AM - 12PM, 1:00PM - 5:00PM, 7:30PM - 11:30PM

Example	December 1, 2007	Saturday	8AM - 12PM
#	Date	Day	Time
1
2
3
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5
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7
8
9
10