Apply Online - Medical Professional Institute

Apply Online

NOTE: This application is NOT to be used by applicants to the Practical Nursing program. If you would like to apply to the Practical Nursing program, please go to the Practical Nursing page and apply first for the Nurse Entrance Test (NET).

Medical Professional Institute is an equal opportunity school, and does not discriminate on the basis of race, religion, national origin, sex, age, handicap, marital status, or status as a disabled veteran. Information provided in this application will not be used for any discriminatory purpose. Please provide any other names used on any of your educational or employment records if they differ from that written below.

Personal Information: (Section 1 of 6)
First name:	Last name:	Middle initial:
Social Security Number:	Date of Birth:	Email Address:
Home Telephone:	Work Telephone:	Alternative Telephone:
Address:	City:	State: Zip code:

Are you a U.S. citizen? Yes No	Are you authorized to work in the U.S.? Yes No	Visa type:

Ethnic origin (optional - statistical purposes only):	Means of transportation: Car Public Transportation Both

Program you're applying to:	Time of class preferred:	Date of Application:

Have you ever applied to Medical Professional Institute before? Yes No	How were you referred to Medical Professional Institute?

Professional Licenses: (Section 2 of 6)
(Do NOT include your driver's license.)
Type:	Reg. #
Expires:	State:

Resources for Tuition: (Section 3 of 6)
Explain your resources for tuition
If your tuition will be provided by another person, please provide his/her name, address, and telephone number, his/her relationship to you, and a signed statement from the person indicating that he/she will assume the responsibility of paying the total amount of the tuition.
Name:	Relationship:
Address:	Telephone #:
Please mail the signed statement to: Medical Professional Institute 388 Pleasant Street Suite 304 Malden, MA 02148

Emergency Contact Information: (Section 4 of 6)
Please state who Medical Professional Institute should contact in case of an emergency.
Name:	Relationship:
Address:	Telephone #:

Educational History/Employment Record:

(Section 5 of 6)

Educational History:

School Name and Location (city, state)

Major course or subject

Dates attended
From | To

Graduated
Yes | No

Degree

High school

College/Technical School

Other Education/Training

Employment Record:

Please provide information about your most recent or present employer.

Last or present company:	Type of business:	Position or title:
Street address:	City:	Brief description of job duties:
State:	Zip code:
Supervisor's name:	Phone number:
Base salary:	Dates worked: From to	Reason for leaving:

Miscellaneous:

(Section 6 of 6)

Please write a paragraph explaining your career goals.

Have you EVER been convicted of a felony or misdemeanor, or charged with a criminal offense?
Yes No
If yes, please furnish details of conviction (offense, location, date, and sentence).

Additional comments:

If you have a promotional code, enter it here:

I grant permission to conduct reference checks, and I release Medical Professional Institute and its affiliats from all liability resulting from this inquiry and from releasing my personal information to the officials whenever requested. I hereby certify that the answers and other information on this application are true and correct and that I understand that any misrepresentation or omission of facts on my part will be justification for immediate dismissal. I understand that Medical Professional Institute does not guarantee employment after this course is completed. I understand, also, that I am required to abide by all rules and regulations of Medical Professional Institute. I understand that Medical Professional Institute reserves the right to discharge students who do not comply with its rules and regulations, and to cancel or delay the starting date of any program, due to insufficient enrollment.

If you have read and understand the above conditions, please click I Agree to submit your application.