Student Fingerprint Completion - Long Beach VA

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* 1. Name

Last

First

Middle Initial

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* 2. School

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* 3. Program type

Nursing

Other (please specify)

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* 4. Date fingerprinting done

MM/DD/YYYY format

Date

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* 5. Best contact email

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* 6. Best contact phone

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* 7. Start date of rotation

Date

Date

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* 8. School Coordinator Name

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* 9. Have you ever or are you currently training at a VA

No

Yes