Step 1 of 3 33% CommentsThis field is for validation purposes and should be left unchanged.Accelerated CMA Program for EmployeesYour Contact InformationThis field is hidden when viewing the formWhich career path are you interested in pursuing?(Required)Select oneCertified Medical AssistantLicensed Practical NursePhysician AssistantMaster of Social WorkLicensed Mental Health CounselorYour Name(Required) First Middle Last Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Your Email Address(Required) Enter Email Confirm Email Are you 18 years of age or older?(Required) Yes No Your Contact NumberHome PhoneMobile Phone(Required)Preferred Method of Contact Email Home Phone Mobile Phone Best Time to Call YouWhen is the best time for us to reach you via telephone?MorningEarly AfternoonLate AfternoonEarly Evening Education InformationPrior Highest Education Level Obtained(Required)Prior highest education level you obtained and for which you received a Diploma or Degree. GED High School Diploma Associate's Degree Bachelor's Degree Master's Degree Professional Licenses and CertificationsPlease list any professional licenses and certifications. Click on the + sign to add more rows. Add RemoveCommentIs there anything else you would like to share regarding your education? Employment InformationAre you legally authorized to work in U.S.?(Required) Yes No Are you a U.S. Citizen or Permanent Resident?(Required) Yes No Do you have work authorization?(Required) Yes No Work Authorization - Expiration Month(Required)Select oneJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberWork Authorization - Expiration Year(Required)Select one20252026202720282029203020312032203320342035Are you a New York State Resident?(Required) Yes No Employer Name White Plains HospitalAre you working full-time or part-time?(Required) Full-time Part-time Job Title(Required)Annual Salary(Required)CommentIs there anything else you would like to share regarding your employment?Consent - Data Accuracy(Required)I certify that all the information submitted by me on this application is true and complete, and I understand that if any false information, omissions, or misrepresentations are discovered, my application may be rejected. I agree(Required)Opt-InBy submitting this form and entering your email and phone number(s) above, you consent to be contacted by a representative from The Audacia Foundation, Inc. Opting-in is not a condition for your application to this program. You can opt-out at anytime by contacting us at support@audaciafoundation.org. I consent to be contacted by The Audacia Foundation, Inc.CAPTCHA
