The Belanger School of Nursing is not authorized by the United States Immigration Service to admit international students. All applicants to the School of Nursing must be United States Citizens or have Permanent Resident Alien status in the United States.

First NameRequired

Middle InitialRequired

Last NameRequired

Please list maiden name and all other names your records have been issued under:Required

Email AddressRequired

Date of BirthRequired

GenderRequired -- choose one -- Female Male Unknown

HispanicRequired -- choose one -- NO YES

US CitizenRequired -- choose one -- Permanent Resident Alien US Citizen

Number and StreetRequired

CityRequired

CountyRequired -- choose one -- Albany County Allegany County Bronx County Broome County Cattaraugus County Cayuga County Chautauqua County Chemung County Chenango County Clinton County Columbia County Cortland County County Outside of New York Delaware County Dutchess County Erie County Essex County Franklin County Fulton County Genesee County Greene County Hamilton County Herkimer County Jefferson County Kings County Lewis County Livingston County Madison County Monroe County Montgomery County Nassau County New York County Niagara County Oneida County Onondaga County Ontario County Orange County Orleans County Oswego County Otsego County Putnam County Queens County Rensselaer County Richmond County Rockland County Saratoga County Schenectady County Schoharie County Schuyler County Seneca County St. Lawrence County Steuben County Suffolk County Sullivan County Tioga County Tompkins County Ulster County Warren County Washington County Wayne County Westchester County Wyoming County Yates County

StateRequired -- choose one -- ALABAMA ALASKA AMERICAN EMBASSY AMERICAN SAMOA ARIZONA ARKANSAS ARMED FORCES THE PACIFIC CALIFORNIA COLORADO CONNECTICUT DELAWARE DISTRICT OF COLUMBIA FLORIDA GEORGIA GUAM HAWAII IDAHO ILLINOIS INDIANA IOWA KANSAS KENTUCKY LOUISIANA MAINE MARYLAND MASSACHUSETTS MICHIGAN MINNESOTA MISSISSIPPI MISSOURI MONTANA NEBRASKA NEVADA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEW YORK NORTH CAROLINA NORTH DAKOTA OHIO OKLAHOMA OREGON PENNSYLVANIA PUERTO RICO RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VERMONT VIRGIN ISLANDS VIRGINIA WASHINGTON WEST VIRGINIA WISCONSIN WYOMING

Zip CodeRequired Zip Code Extension

Cell PhoneRequired Cell Phone Area Code Cell Phone Exchange Cell Phone Number Cell Phone Extension  Ext: 

Current EmployerRequired

Current Title or Position:Required

Current Employer Address: CityRequired

Current Employer Address: StateRequired -- choose one -- ALABAMA ALASKA AMERICAN EMBASSY AMERICAN SAMOA ARIZONA ARKANSAS ARMED FORCES THE PACIFIC CALIFORNIA COLORADO CONNECTICUT DELAWARE DISTRICT OF COLUMBIA FLORIDA GEORGIA GUAM HAWAII IDAHO ILLINOIS INDIANA IOWA KANSAS KENTUCKY LOUISIANA MAINE MARYLAND MASSACHUSETTS MICHIGAN MINNESOTA MISSISSIPPI MISSOURI MONTANA NEBRASKA NEVADA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEW YORK NORTH CAROLINA NORTH DAKOTA OHIO OKLAHOMA OREGON PENNSYLVANIA PUERTO RICO RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VERMONT VIRGIN ISLANDS VIRGINIA WASHINGTON WEST VIRGINIA WISCONSIN WYOMING

NameRequired

What is your highest level of education?Required -- choose one -- College GED High School

Please confirm the program you are applying forRequired -- choose one -- Nursing Associates Degree

Which year do you plan to enter?Required -- choose one -- Fall 2025

VeteranRequired -- choose one -- Not a veteran Veteran = Yes

How many years have you been with this employer?Required

Please indicate the anticipated or completed dates for the prerequisite courses you have completed.

AlgebraRequired

BiologyRequired

ChemistryRequired

Academic credentials provide a perspective of you as a student. Please respond to the following statements to provide the selection committee with further personal insight.

1. Discuss activities, interests and/or volunteer experiences you may have had the opportunity to participate in.Required

2. Describe an experience in which you may have had to persevere to succeed.Required

3. Explain why you feel you have more potential than your academic record indicates, if appliable. Be specific with attributes you’ve developed that will allow you to be successful in nursing school.Required

Secondary School 1 Dates: (Example: 2015-2019)Required

Secondary School 2 Dates: (Example: 2015-2019)Required

Secondary School 1 City and State: (Example: Boston, MA)Required

Secondary School 2 City and State: (Example: Boston, MA)Required

Post-Secondary Institution #1 Date of Attendance:Required

Post-Secondary Institution #2 Date of Attendance:Required

Post-Secondary Institution #3 Date of Attendance:Required

Post-Secondary Institution #4 Date of Attendance:Required

Post-Secondary Institution #1 Location (City, State):Required

Post-Secondary Institution #2 Location (City, State):Required

Post-Secondary Institution #3 Location (City, State):Required

Post-Secondary Institution #4 Location (City, State):Required

Post-Secondary Institution #1 Major:Required

Post-Secondary Institution #2 Major:Required

Post-Secondary Institution #3 Major:Required

Post-Secondary Institution #4 Major:Required

Post-Secondary Institution #1 Credential Earned: (Diploma, Certificate, Degree, Number of Credits)Required

Post-Secondary Institution #2 Credential Earned: (Diploma, Certificate, Degree, Number of Credits)Required

Post-Secondary Institution #3 Credential Earned: (Diploma, Certificate, Degree, Number of Credits)Required

Post-Secondary Institution #4 Credential Earned: (Diploma, Certificate, Degree, Number of Credits)Required

High School Equivalency Exam/GED Date:Required

Previous Employer #1: Dates of EmploymentRequired

Previous Employer #2: Dates of EmploymentRequired

Previous Employer #3: Dates of EmploymentRequired

Previous Employer #4: Dates of EmploymentRequired

Previous Employer #1: Title of PositionRequired

Previous Employer #2: Title of PositionRequired

Previous Employer #3: Title of PositionRequired

Previous Employer #4: Title of PositionRequired

Previous Employer #1 Name:Required

Previous Employer #2 Name:Required

Previous Employer #3 Name:Required

Previous Employer #4 Name:Required

Previous Employer #1 Location (City, State):Required

Previous Employer #2 Location (City, State):Required

Previous Employer #3 Location (City, State):Required

Previous Employer #4 Location (City, State):Required

E-Signature (Type Name) and Date:Required

If you have previously applied to this school, please indicate the date of your original application.Required

Post-Secondary Institution #1Required

Post-Secondary Institution #2Required

Post-Secondary Institution #3Required

Post-Secondary Institution #4Required

Secondary School #1 NameRequired

Secondary School #2 NameRequired

Please list all work experiences, both full and part time, for the past 5 years beginning with the most recent.

Please describe your plan to complete the prerequisites not completed at this time.Required