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Appendix I. Application for Admission to the Nursing Pre-licensure Program
Return application to:
Secretary to Department of Nursing
BSC 416
Office Use Only
Date Received:
Application Processed Throughout the Year
Current Muskingum University Student
Applying to BSN Program
Transfer Student
Applying to RN-BSN Program
Mr.
Miss
Mrs.
Ms
Name:_________________________________________________________
First
Middle or Maiden
Last
Home Address __________________________________________________
Number and Street
City
State
Zip
Mailing Address (if different)
______________________________________________________________
Number and Street
City
Phone_________________________
Office or Cell
SSN__________________________
Have you been accepted to the University?
If no, have you applied?
Zip
________________________
Area Code & Number (Home)
1.
State
E-mail___________________
Yes__________
Yes__________
No__________
No__________
2. Have you been a full-time _____or part-time_____ student at Muskingum?
3. Place a check in the blank beside the following required courses that you have completed with a
grade of C or higher. Indicate courses in which you are currently enrolled by marking “IP” (in
progress) in the blank space beside the course.
________ Chemistry 111: General Chemistry I
________ Chemistry 115: Organic-Biochemistry
________ Biology 121: Anatomy and Physiology I
________ Biology 122: Anatomy and Physiology II
________ English 121: Composition
________ Psychology 101: Introduction to Psychology
4. Is your cumulative GPA (at all colleges, universities, technical schools attended) at a 2.5 or higher
on a 4.0 scale? Yes_______ No_______
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5. List all colleges, universities or technical schools you have attended.
6. Attach the following information to this application form:
Photocopies of all academic work completed at educational institutions
University (transcripts and/or grade sheets).
other than Muskingum
INCOMPLETE APPLICATIONS WILL BE RETURNED
I hereby apply to the Muskingum University Department of Nursing and acknowledge that the
information is complete and accurate. I have never been convicted of a felony, which I understand
would prohibit me from licensure as a Registered Nurse. If accepted, I agree to comply with
regulations of the Department of Nursing and Muskingum University.
Signature of Applicant _________________________________ Date________________
Nov, 2010