First NameRequired

Middle NameRequired

Last NameRequired

Preferred NameRequired

Email AddressRequired

Social Security Number

Confirm Social Security Number

Date of BirthRequired Enter date as MM slash DD slash YYYY

SexRequired -- choose one -- Female Male Unknown

EthnicityRequired -- choose one -- AMER. IND/ALASK ASIAN/PAC ISLAND BLACK, NON HISP CAPE VERDEAN EGYPTIAN HAITIAN HISPANIC OTHER WHITE, NON HISP

Street 1Required

Street 2Required

CityRequired

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

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

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

Mail Street 1Required

Mail Street 2Required

Mail CityRequired

Mail 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

Mail Zip CodeRequired Mail Zip Code Extension

Emergency First NameRequired

Emergency Last NameRequired

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

Emergency RelationshipRequired -- choose one -- Aunt Father Guardian Mother Parent Uncle

Have you completed any college courses? If you have select college, if not select either High School or GED.Required -- choose one -- College GED High School

High School or GEDRequired

High School or GEDRequired

College NameRequired

College NameRequired

College NameRequired

College NameRequired

College NameRequired

Anticipated Starting SemesterRequired -- choose one -- Fall 2027

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

Intended Practice State/U.S. TerritoriesRequired -- choose one -- AK - Alaska AL - Alabama AR - Arkansas AS - American Samoa AZ - Arizona CA - California CO - Colorado CT - Connecticut DC - District of Columbia DE - Deleware FL - Florida GA - Georgia GU - Guam HI - Hawaii IA - Iowa ID - Idaho IL - Illinois KS - Kansas KY - Kentucky LA - Louisiana MA - Massachusetts MD - Maryland ME - Maine MI - Michigan MN - Minnesota MO - Missouri MP - Northern Mariana Islands MS - Mississippi MT - Montana NC - North Carolina ND - North Dakota NE - Nebraska NH - New Hampshire NJ - New Jersey NM - New Mexico NV - Nevada NY - New York OH - Ohio OK - Oklahoma OR - Oregon PA - Pennsylvania PR - Puerto Rico RI - Rhode Island SC - South Carolina SD - South Dakota TN - Tennessee TX - Texas UT - Utah VA - Virginia VI - U.S. Virgin Islands VT - Vermont WA - Washington WI - Wisconsin WV - West Virginia WY - Wyoming

Your academic credentials show your performance as a student. Please respond to the following prompts in detail to help the selection committee learn more about you as an individual.

1. Describe in detail why you want to be a nurse.Required

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

3. Describe personal attributes you have developed that will allow you to succeed in nursing school.Required

Employer #1: Dates of EmploymentRequired

Employer #2: Dates of EmploymentRequired

Employer #3: Dates of EmploymentRequired

Employer #1: Title of PositionRequired

Employer #2: Title of PositionRequired

Employer #3: Title of PositionRequired

Employer #1 Name:Required

Employer #2 Name:Required

Employer #3 Name:Required

Employer #1 Location (City, State):Required

Employer #2 Location (City, State):Required

E-Signature (Type Name):Required

Please fill out the following questions regarding your current employer. If you are not currently employed, please enter "none" on any required questions.

4. If you have previously been enrolled in a RN program, please identify the institution and explain why you are no longer enrolled.Required