Suffolk County Community College
SCHOOL OF NURSING
University Hospital at Stony Brook
Campus Card Application
Directions for Stony Brook Campus Card Applications
USE BLACK/BLUE PEN ONLY
Complete all of the following items:
Section 1
Name:
Stony Brook ID Number
Social Security#:
Status:
Department:
Title:
Last & First Name
(only if you already have one)
Do not fill in this section
Check off the “Student” box
Write in “Clinical Ed – SCCC”
Write in “Student Nurse”
Section 2
Home Address*
put your address on the first line only
SCCC Email Address
put your email address on 2nd line of “home address”
Home Phone
Date of Birth
SIGN BOTTOM OF SHEET
*No Abbreviations. e.g.; Street, Lane, Drive, Road NOT St, Ln, Dr, Rd. P.O. Box addresses acceptable
ONLY if that address is listed on the student’s driver’s license]
Application form on following page 
8/20
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