APPLICATION FOR ADMISSION TO THE B.S. NURSING PROGRAM SWAU Students
	SSL Certificate       Complete the form and click next at end of form (no application fee required)   Double check all spelling and be as complete as possible.
	This application is only for those who have previously applied to SWAU. Personal Data Your Full Legal Name:    Jr. II III IV Sr.   Last Name (Family Name or Surname) First Name Middle Name Suffix    Mr. Ms. Miss Mrs. Dr.   First Name you prefer to be called Previous Last Name(s) Title Date of Birth:    January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933   Gender:   Male     Female   Month Day Year   U.S. Social Security Number:         (This is a secure server, your personal information will be safe) E-Mail Address:      FAX number:      (If available)   (If available) Home Address:    Number and Street City State Zip Code Country (if not USA) Phone Numbers:      Home Phone Cell Phone (if available) Work Phone (if available) Temporary Address: (if different from Home Address)    Number and Street City State Zip Code Country (if not USA) Temporary Phone Number: (if different from Home Phone)         Date you are leaving this address:   January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2007 2008 2009 2010 2011 2012 2013   Month Day Year Your Religion:   Academic Information When do you wish to start your attendance?                     select date August 2012 (fall semester) January 2013 (spring semester) August 2013 (fall semester) Have you applied to Southwestern Adventist University Nursing program before?     Yes     No Are you presently a Southwestern Adventist University student?     Yes     No What is your license status?    None   enrolled in an LVN program     when will it be completed?   January February March April May June July August September October November December    2007 2008 2009 2010 2011 2012 2013   Month Year   currently licensed as LVN when did you receive licensure?   January February March April May June July August September October November December    2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948   Month Year   how long have you worked as an LVN? 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   Years   enrolled in an RN program     when will it be completed?   January February March April May June July August September October November December    2012 2013 2014   Month Year   currently licensed as RN when did you receive licensure?   January February March April May June July August September October November December    2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948   Month Year   how long have you worked as an RN? 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   Years High School (Secondary Education Level)  Name of High School (whether you graduated or not):             City        State or Country  Which of the following best applies to you?   Graduated from High School Year:   2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948   Will graduate from High School Year:   2012 2013 2014   Passed the GED or a state high school equivalency test   Year:   2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948   Will take the GED or a state high school equivalency test   Year:   2012 2013 2014   Will not complete High School nor take GED   List each College or University you have attended   (List each school one time only):    School City State or Country Degree(s) earned Dates of attendance    School City State or Country Degree(s) earned Dates of attendance    School City State or Country Degree(s) earned Dates of attendance    School City State or Country Degree(s) earned Dates of attendance    School City State or Country Degree(s) earned Dates of attendance    School City State or Country Degree(s) earned Dates of attendance Please ask all Colleges and Universities you have attended to send official transcripts to: Admissions Office Southwestern Adventist University Keene, TX 76059 If you have completed less than 12 college hours, we will also need an official transcript from the last High School you attended. If you took the GED, then we will also need an official GED Test Report Personal Conduct   In High School or College have you been placed on probation for disciplinary reasons?   Yes No   In High School or College have you been suspended for disciplinary reasons? Yes No   In High School or College have you been dismissed for disciplinary reasons? Yes No     Have you been convicted of a misdemeanor? Yes No   Have you been convicted of a felony? Yes No           If you have been incarcerated, last release date:   January February March April May June July August September October November December after 2009 2009 2008 2007 2006 2005 2004 2003 2002 before 2002      Month  Year     Have you used tobacco in the past six months? Yes No   Have you used alcohol in the past six months? Yes No   Have you used drugs in the past six months? Yes No If you answer YES to any of these questions in this section, you need to explain in the space below (what/why/when/where,etc). Include a statement of your goals for the future:    Work Experience Describe the last two positions you held:     Position or type of work Employer Dates     Position or type of work Employer Dates Previous Nursing Experience Describe all of your health-care related experiences:   (Provide description as well as approximate length of time) Goals Describe your professional health-care related goals: References Please obtain three professional references from teachers, employers, or supervisors.     Name Address Phone     Name Address Phone     Name Address Phone Student Pledge By electronically submitting this application, I certify that the above statements are correct and complete.   I understand that incomplete or false information may make me ineligible for admission to or continuation at Southwestern Adventist University.