Advanced Placement Work Verification

This form serves as official verification of your qualifying work experience.

Eligibility Requirement: All applicants must have full-time work experience (2,080 hours per year, or a combination of part-time hours totaling 2,080 hours) as an LVN, Psychiatric Technician, Paramedic, or Military Medic for a minimum of one (1) year within the past three (3) years.

Multiple Employers: If your qualifying experience was completed at more than one facility, you must submit a separate form for each employer.

Courtesy Notification: Before submitting this form, please notify your employer/supervisor that they will receive an email requesting verification.

Review Process: Once submitted, the form will automatically be routed to your supervisor for review and approval. You will receive a completed copy once your employer signs the form.

Verification Rights: United Nursing College (UNC) reserves the right to contact your supervisor directly by phone or email to verify the information provided.

Applicant Name*

Applicant Email Address*

example@example.com

Applicant Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Employer Name/Organization*

Employer Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Supervisor's Name*

Supervisor's Title/Position*

Supervisor's Email Address*

example@example.com

Supervisor's Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Position title at this organization*

Short description of work responsibilities*

Start Date*

End Date

Leave blank if still employed

Employed full-timeEmployed part-time

Longer than one yearLess than one year

Please indicate how many months you have been employed full-time.*

3 years (156 weeks)2 years (104 weeks)1 year (52 weeks)Less than 1 year (<52 weeks)

If you've been employed less than 1 year (<52 weeks), please indicate the number of weeks you have been employed.*

Please indicate your average number of hours worked per week while employed at this facility.*

Optional comments