SWAU and AS Nursing Program application

APPLICATION FOR UNDERGRADUATE AND
B.S. NURSING PROGRAM

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.

Personal Data
Your Full Legal Name:


Last Name (Family Name or Surname)	First Name	Middle Name	Suffix

First Name you prefer to be called	Previous Last Name(s)		Title

Date of Birth:					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:
			Month	Day	Year

Your Religion:

Nation of Citizenship: Nation of Birth:
	If you are not a U.S. Citizen, indicate your U.S. Immigration Status:
	Non-Resident Alien/Foreign Student
	Permanent Resident with Green Card
	Other

Ethnicity: Check which one applies. Your response is voluntary and will be used in a nondiscriminatory manner consistent with applicable civil rights laws
	Black or African American	Native American or Alaskan Native	Asian or Pacific Islander
	Hispanic	White/Caucasian	Other/Unknown

Academic Information

When do you wish to start your attendance?

Have you applied to Southwestern Adventist University Nursing program before? Yes No

Housing Plans: Dormitory Off-Campus Housing

Financial Aid:

	Will you be applying for Financial Aid? (U.S. Citizens and U.S. Residents may be eligible for Financial Aid)	Yes No
	Will you be applying for benefits under the G.I. Bill? (U.S. veterans and dependents)	Yes No

What is your license status?
	None
	enrolled in an LVN program	when will it be completed?
			Month	Year
	currently licensed as LVN	when did you receive licensure?
			Month	Year
		how long have you worked as an LVN?
			Years
	enrolled in an RN program	when will it be completed?
			Month	Year
	currently licensed as RN	when did you receive licensure?
			Month	Year
		how long have you worked as an RN?
			Years

WHich one of the following academic classifications best applies to you at this time?

	Not Graduated from High School
	Graduated from High School, no college credit earned
	College Freshman (1−12 sem hrs)
	College Freshman (13−23 sem hrs)
	College Sophomore (24−55 sem hrs)
	College Junior (56−89 sem hrs)
	College Junior (56−89 sem hrs) with a previously earned two-year college degree
	College Senior (90+ sem hrs)
	College Senior (90+ sem hrs) with a previously earned two-year college degree
	Already have a four-year college degree

Indicate the tests you have taken: (Check all that apply)

	SAT (Scholastic Aptitude Test)	ACT (American College Test)
	CLEP (College Level Exam Program)	GED (General Education Development)
	Michigan Test of English	TOEFL (Test of English as a Foreign Language

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:
	Will graduate from High School	Year:
	Passed the GED or a state high school equivalency test	Year:
	Will take the GED or a state high school equivalency test	Year:
	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:
	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.