School of Nursing Application for Admission

Nursing Program:
*$25 fee is required for LPN and RN pre-admission test.
Anticipated Entry Date:	/
Title:
First Name:
Middle Name:
Last Name:
Other names that may appear on educational records:
Address:
City, State Zip:	,
New York State Resident:	Since:
County of Residence:
Country of Citizenship:
Home Telephone:
Work Telephone:
Social Security Number:
Date of Birth:	,
Single, Divorced or Widowed Married
Have you previously applied for admission to this program?	If so, when?
Are you a Northeast Health employee?	Affiliate name:
Are you an LPN?

SECONDARY EDUCATION: List all high schools attended.

Please request that each school send an official transcript to the School of Nursing.

From	To	Name of School	City and State	Date of Graduation

POST SECONDARY EDUCATION: List all formal education beyond high school.

Please request that each school send an official transcript to the School of Nursing.

From	To	Name of School	City and State	Degree Earned

If you earned a GED (General Equivalency Diploma), indicate date earned:
Please request that an official copy of GED scores be sent to the School of Nursing.
Was any of your education outside the United States?
If yes, where? Dates

If you earned a GED (General Equivalency Diploma), indicate date earned:

Please request that an official copy of GED scores be sent to the School of Nursing.

Was any of your education outside the United States?

If yes, where? Dates

Prerequisite Courses: Have you completed the prerequisite courses with a grade of C/70 or better?

These courses may be completed through high school or college level work.

Algebra
Biology w/Lab
Chemistry w/Lab

Please list college level courses which you are currently taking:

College Level Course	College

EMPLOYMENT: Please list your employment history beginning with the most recent.

From	To	Position	Employer	City & State

Check each that applies to you:	United States Citizen Permanent Resident In the United States on a Visa Type of Visa

Check each that applies to you:

United States Citizen
Permanent Resident
In the United States on a Visa
Type of Visa

Please bring original visa or green card to the school

Please select one (Optional)

Please select one (Optional)

Please indicate your first source of information concerning the School of Nursing:

Candidates for admission are considered without discrimination on the basis of age, gender, race, ethnicity, national origin, religion, disabling condition or sexual orientation.

Have you ever been convicted of a crime?
If "YES", please describe fully the criminal conviction(s), listing the nature and date of the offense and your rehabilitation since the conviction(s):

Note: A "yes" answer does not automatically disqualify you from being accepted since the nature and date of the offense will be considered.

NOTICE TO ALL APPLICANTS: THE LAW REGULATING THE PRACTICE OF NURSING STATES THAT THE BOARD MAY DENY A CONVICTED FELON A LICENSE OR THE PRIVILEGE OF SITTING FOR THE EXAMINATION. (SECTION 4712.28 OF THE REVISED CODE.)

The information given on this application is complete and true to the best of my knowledge.
I understand that falsification or deletion of pertinent information may result in admission denial, withdrawal of acceptance or, once enrolled, dismissal from the program.

Application Check List: Failure to complete this application will delay the application process. Please check off the following items once completed:

Be sure you have answered all items on this application

Request an official transcript from each school you have attended be sent to the School of Nursing

Complete the essay on the following page

ESSAY: Write a brief essay (several paragraphs) which address one or more of the following:

Why you have chosen the profession of nursing.
Describe what, if any, previous experience you have had in the healthcare field.
Explain why your academic record(s) may not demonstrate your full potential as a student.