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INTERNATIONAL STUDENT INTEREST FORM

We appreciate your interest in the International Healthcare Professional Bridge Program. Please PRINT the answers to
the questions below and please FULLY complete this form. Nothing is guaranteed in life, but we guarantee you our best
efforts in assisting you with your international career goals! Your success is our success!
Date Of Application: Country: □ LICENSED Healthcare Provider Applications will receive consideration without
discrimination because of race, creed, color, sex, sexual
□ Healthcare AIDE orientation, age, national origin, handicap or veteran status.

How did you learn about the Program? □Web □Friend/Relative: Name: __________________ □Other: _____________

Name ___________________________________________________________________________________________
LAST FIRST MIDDLE

Date of Birth: _________Gender: _______ Country of Birth: _____________ Country of Citizenship: ________________

Current Address: __________________________________________________________________________________

NUMBER STREET CITY STATE COUNTRY POSTAL CODE

ID # ________________ Cell Phone # ___________________ Email address _______________________________

DO YOU HOLD AN ACTIVE HEALTHCARE PROVIDER LICENSE? □ YES □ NO

If YES, in which Country/State: ___________________________ Years of Experience: ____________________________
Type of licensure (such as Registered Nurse, Doctor, Physical Therapist): _______________________________________
Area of Expertise: _________________________________ School Attended: Please fill in the education info below.
► Please attach copies of License, Transcripts of Records (TOR), Related Learning Experience Form (RLE)

ARE YOU CURRENTLY EMPLOYED AS A HEALTHCARE PROFESSIONAL? □ YES □ NO

If YES, list your current Employer’s Name __________________________ Telephone Number: ____________________
Employer’s Address __________________________________________________________________________________
Job Title, Describe your work __________________________________________________________________________
► Please attach a copy of your Resume
HAVE YOU EVER TAKEN AN ENGLISH PROFICIENCY TEST (SUCH AS TOFEL/ IELTS)? □ YES □ NO
If YES, list the type of test: ___________________ List Scores for Reading___ Listening ____ Speaking ___ Writing ____
If NO, on a scale 0-5, Score how well do you Speak English: ______ Read English: ______ Write English: _______
0-No English, 1-Basic English, 2-Limited Working English, 3-Professional Working English, 4-Full Professional English, 5-Native/Bilingual English
► Please attach a copy of the test scores, if applicable.

HAVE YOU EVER TAKEN THE NCLEX (NATIONAL COUNCIL LICENSURE EXAMINATION TEST)? □ YES □ NO
If YES, in which State? _____________ Did you pass? □ YES □ NO Do you hold current license in that state? □ YES □ NO
Course of No. Yrs. Year of
School Name and Location of School Degree/ Diploma
Study Completed Graduation
E
D Graduate
U
C
Professional
A
T
I College/University
O
N
High School

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Are you less than 18 years old?  Yes  No
Have you ever been convicted of, pled guilty, no contest, or nolo contendre to a crime?  Yes  No
Have you ever had your professional license suspended or revoked?  Yes  No
Have you ever been refused entry into or deported from any country, including USA?  Yes  No
If YES to any of the above questions, please explain: _____________________________________________________
_________________________________________________________________________________________________
DO YOU HAVE A CURRENT PASSPORT? Yes No If YES, list the Country of Issuance: ___________________
►
\\ Please include a copy of the front page of your passport, and bring the passport with you, if applicable.
PLEASE CHECKOFF BELOW ALL DOCUMENTS ATTACHED TO THIS APPLICATION:
□ 1. Copy of current Healthcare Professional License □ 5. Passport Photo 2 x 2
□ 2. English copy of Transcripts of Records (TOR)) □ 6. Copy of Passport, if applicable
□ 3. English copy of Related Learning Experience Form (RLE) □ 7. Copy of the TOEFL scores, if applicable
□ 4. Resume □ 8. Other: ___________________________
ADD ANY ADDITIONAL INFORMATION TO SUPPORT YOUR APPLICATION
_______________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________

APPLICANT’S SIGNATURE
1. I certify that the information I provided in this Application is true, correct, and complete. I understand that if selected,
any misrepresentations and/or omission of fact on this application may result in disqualification and therefore dismissal
from the Program.
2. I understand that successful pre-selection by HRGC does not guarantee admission in the International Healthcare
Professional Bridge Program, as numerous requirements must be met in order to secure enrollment, including passing a
background check and demonstrating sufficient financial funds to support study in United States.
International Student’s Signature: ____________________________________ Date: _____________________
FOR OFFICE USE ONLY
This Application & Supportive Documentation were reviewed by ___________________________________ at HRGC.
This Applicant:
□ Meets Essential Minimum Qualifications (Required to move forward with the Program)
□ Possess Asset Qualifications (Not essential, but important for successful completion of the Program)
This Applicant:
□ Is SUITABLE for HRGC’s International Healthcare Provider Bridge Program as:
□ LICENSED HCP □ RN □ OTHER: ____________________________________________________
□ FUTURE HCP □ __________________________________________________________________

□ Is NOT SUITABLE for HRGC’s International Healthcare Provider Bridge Program.

□ Recommendations: ____________________________________________________________________

____________________________/__________ ___________________________/___________
HRGC Reviewer Signature Date HRGC President Approval Date

Excellence is never an accident! It is the result of high intention, sincere effort, intelligent direction,
skillful execution, and the vision to see obstacles as opportunities.

© HRGC 2022 08 18
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