APPLICATION FOR ADMISSION

BACHELOR OF SCIENCE IN NURSING (BSN) PROGRAM

2009

Please Note: This application is for students seeking initial licensure as Registered Nurses.

NAME: ___________________________________________________________________________________________________

      Last                                                          First                                                    Middle                                            Maiden

MAILING ADDRESS_______________________________________________________________________

    Street Address/P. O. Box

_______________________________________________________________________________________________________________________

   City                                                                                      State                                        County                                         Zip Code

E-MAIL ADDRESS_________________________      SS#__________________________________________

HOME PHONE # __________________________  CELL PHONE # ________________________________

         Include Area Code                                                                                  Include Area Code

IN CASE OF EMERGENCY, NOTIFY_____________________________________________________________________

RELATIONSHIP_____________________________________________PHONE # ___________________________________

Instructions for Completing Application

Applicants seeking admission to the Generic Bachelor of Science in Nursing (BSN) full-time program must submit the following information to the School of Nursing no later than January 15, 2009, to be considered for admission in the Summer Semester, 2009.

• Completed and notarized Generic BSN Application Form.  Applications returned without notarization will not be considered.

• Evidence of Admission to the University of West Georgia.  If currently enrolled at the University of West Georgia, please attach a copy of current class schedule. If not currently enrolled, please attach a copy of letter of acceptance to the University of West Georgia. Please note: When applying to the University of West Georgia, please mark the application for entrance for summer semester, 2009. If previously enrolled but have not attended classes recently, or if applied earlier and did not enroll, active status may have been dropped.  Please contact the Admissions Office to clarify status.

• Satisfactory completion of a nursing entrance test.

Detailed information about the test will be mailed to you after receipt of the application.

• Submission of transcripts. It is the responsibility of the applicant to see that ALL TRANSCRIPTS of coursework done at a school other than University of West Georgia are sent to the Admission’s Office.  These transcripts must be received in the Registrar’s Office by February 1 to be considered for admission.

Please send application to:                    Generic BSN Admissions Committee

                                                                  University of West Georgia, School of Nursing

                                                                  1601 Maple Street

                                                                        Carrollton, GA 30118-5180

1. Presently attending a college or university?     Yes     No

If yes, identify the school____________________________________________________

2. COLLEGE(S) ATTENDED                      DATES ATTENDED            DIPLOMA/DEGREE

_____________________________                 ______________               __________________________

_____________________________                 ______________               __________________________

_____________________________                 ______________               __________________________

_____________________________                 ______________               __________________________

_____________________________                 ______________               __________________________                  

3. Currently hold license as a Licensed Practical Nurse?                 Yes     No

If Yes, please provide copy of license with application.

4. Ever been arrested, convicted, sentenced, pled guilty, pled nolo contendere or given first offender status for any felony, a crime involving moral turpitude, or a crime violating a federal law involving controlled substances or dangerous drugs or a DUI or DWI?        Yes     No

Note:  Criminal Background checks may be required prior to student participation in clinical learning opportunities. Inability to complete clinical requirements may interfere with successful completion of degree requirements.

5. Has any other licensing board or agency in Georgia or any other state ever:
   1. Denied license application, renewal, or reinstatement?                            Yes     No
   2. Revoked, suspended, restricted, or probated license?                            Yes     No
   3. Requested or accepted surrender of license?                                          Yes     No
   4. Reprimanded, fined, or disciplined?                                                        Yes     No

If “Yes” to any item in question # 4 or #5, an appointment must be made with the Chair of the School of Nursing for consultation. Information from consultations will remain confidential. This consultation is necessary to determine the potential for licensure as a Registered Nurse in Georgia. State boards of nursing have the legal authority to grant or deny licensure. Completion of a BSN program does not imply approval by a board of nursing for licensure.

NOTARY

STATE OF __________________________­_______________COUNTY OF ___________________________________________

_________________________________________________________, BEING DULY SWORN SAYS THAT HE/SHE IS

APPLICANT’S NAME

THE PERSON REFERRED TO IN THE FOREGOING APPLICATION; THAT THE STATEMENTS THEREIN CONTAINED IS TRUE.

                                                                                                ______________________________________________________________

                                                                                                LEGAL SIGNATURE OF APPLICANT

SWORN TO BEFORE ME THIS_________________________DAY OF ______________________________________________

NOTARY PUBLIC_____________________________________________SEAL

COMMISSION EXPIRES_______________________________________

Rev. 4/8/08