NCLEX ASSISTANCE REGISTRATION FORM

Name: _________________________________________

Address: ___________________________________________________________________________

City: ______________________________________ Province: _______________________________

Tel Number: ________________________________ Email: _________________________________

Date Obtained Degree: _______________________ Specialty: _______________________________

Areas covered during study: Medical _____ Surgical _____ Ob/Gyn _____ Peds _____ Psych ______

Applied for:
CGFNS _______ Score _________
TSE __________ Score _________
TOEFL _______ Score _________

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Please sign below:

I hereby would like to take advantage of your NCLEX Assistance Program.

I fully understand that registering for this service does NOT in anyway guarantee passing results in the
NCLEX and that this fee is NON-REFUNDABLE.

I enclose a money order to register myself (Please check one):

US $195 ____ Basic NCLEX exam program

US $525 ____ All inclusive NCLEX Assistance Program

I would like to sit the NCLEX exam in _______________ (Tentative date only)

Taking advantage of this service DOES NOT obligate you to IHR in ANYWAY, nor you have to
take advantage of this Program to apply through us. This is ONLY a service to assist candidates.

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Name

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Signature

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Date