University of West Georgia School of Nursing

Last Name

First Name

UWG ID# (Last 6 digits)

917

Middle Name

Maiden Name

Street Address/P.O. Box Include/Apartment #

City

State

County

Zip

Email Address

Home Phone #

Cell Phone #

In case of emergency, notify

Relation

Emergency Phone #

Presently attending a college or university?

Yes No

If yes, identify the school

Nursing Program attended:

Date of Graduation:

NLNAC Accredited:

Yes No

Please rank your campus choices with 1 being your first choice and so on:

College(s) Attended

College Name
Dates Attended
Diploma/Degree

Georgia RN license number

Employer

Employer Address

Employer City

Employer State

Has any state board of nursing ever imposed disciplinary action against you?

Yes No

If “Yes,” please attach a notarized letter explaining the details of the action.

Please send supporting application documents to:

RN-BSN Admissions Committee
University of West Georgia
School of Nursing
1601 Maple Street
Carrollton, GA 30118-5180