OUR PATHWAY

PROCESSING CENTER
“Our way to success”

Instruction: Kindly fill out all the information needed. Please be sure to complete every field and check
every box.
I. Write your name exactly as it appears in the following:
LAST NAME FIRST NAME MIDDLE NAME SUFFIX
Passport
Nursing License

Nursing Diploma
Single name if married (for
women)
Married Name
II. Fill out the following details
FB user name
Email address
Birth Date
Gender
Ethnicity
Status
Nine-digit SSN
(Social Security Numbers)
Mother's Maiden Name
Mobile number
Overseas mobile number
III. Security Questions
Who is your Childhood hero?
What was your first school?
What year did you graduate
from high school?
Country
When did you graduate in
College?
IV. Complete mailing address
Note: Middle east address is applicable if you are a Citizen
House no. , Unit no. Brgy. /Village
Floor and Building City/Municipality
Street State/Province
Block and Lot 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 Exam name
Profession License number (If granted)
Date of examination
V. Elementary School
Note: If the name of your school changes, please list both the old and new names.
Name of Elementary School
City/Municipality Number of years attended
State/Province Month and year started
Country Month and year completed
Please indicate any further schools here:
Name of Elementary School
City/Municipality Number of years attended
State/Province Month and year started
Country Month and year completed
 VI. High School
Note: If the name of your school changes, please list both the old and new names.
Name of High School
City/Municipality Number of years attended
State/Province Month and year started
Country Month and year completed
Please indicate any further schools here:
Name of High School
City/Municipality Number of years attended
State/Province Month and year started
Country Month and year completed

VII. Nursing School

Note: If the name of your school changes, please list both the old and new names.
Name of Nursing School
City/Municipality Number of years attended
State/Province Month and year started
Country Month and year completed
Course
Please indicate any further schools here:
Name of Nursing School
City/Municipality Number of years attended
State/Province Month and year started
Country Month and year completed
Course
VII. EXAM HISTORY : Previous NCLEX Exam
State ❏NCLEX RN
Type of exam
Date of Exam ❏NCLEX PN
VII. Please provide an answer to the following query.
Is this your first time to
take NCLEX?
State you want to apply for
Do you have an existing USERNAME: Do you have an existing Pearson USERNAME:
online account to the state Vue account? If so, kindly state the
you want to apply? If so, PASSWORD: log-in information. PASSWORD:
kindly state the log-in
information.
VIII. REQUIREMENTS (Clear Scanned Copy)
❏ Updated Passport with signature
❏ Transcript of Records
❏ Nursing Diploma
❏ PSA Birth Certificate
❏ Marriage Certificate (If applicable for Female only)
❏ Updated PRC ID (Back & Front in one page)
❏ Board rating
❏ 2x2 Passport size Photo
❏ RLE
IX. AGREEMENT
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.

Signature over Printed Name Date

Jeremiah 29:11
For I know the plans I have for you,” declares the LORD, “plans to prosper you and not to harm you, plans to give
you hope and a future.