If you would like to download the form and send it to the Pee Dee AHEC, please click on the link below. If you would like to continue to use the online version of the form, simply fill out the information below.
Click here to download file
Fill the form out completely. Uncompleted forms will be discarded. To move the form, click and hold on the word move in the top right hand corner and drag it where desired.
Fields marked with a * are required.
* Your First Name:
Your Middle Name:
* Your Last Name:
Your Maiden Name:
Suffix:
* Your Email:
* Your Date of Birth:
* Your Personal ID (Birth Month/Birth Day/Last 4 Digits of Social Security #:
* Gender:
* Your Race:
* Licensure:
Other Licensure (if applicable):
* Your Department:
Phone Number 1:
Phone Number 2:
Fax Number:
* Your Address:
* City:
* State:
* Zip Code:
* County:
* Name of Your Employer:
* Employer's County:
* Your Work Address:
* Work City:
* Work State:
* Work Zip Code:
By submitting this form you authorize the Pee Dee AHEC to release information from this application and letters of reference as they may deem appropriate under guidelines of the Freedom of Information Act. It also authorizes the use of my image and statements if selected to participate. It is acknowledged that the information provided in this application is accurate. It is also acknowledged that upon submission of this application, you have obtained consent from your Immediate Supervisor and that he/she agrees to this: 'I acknowledge that the applicant meets the eligibility requirements for this course and that the employing agency is responsible for determining the competency of the LPN through clinically supervised return demonstration based on agency-specific policies, procedures, and standing orders'.