Southern
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Nursing
ADN
toBSN
Application
NHTI
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! I f
I I
f I I f
Full Legal Name
First
Middle
Former Last Name (if any)
Home Address
Box, Apt., or StreetName and Number
State
Home Telephone
Zip Code
Cell Phone
Area Code
Area Code
Email
Birth Date
NIonth
Gender: IUale
IFemale
Ethnicity (optional):
Are you Hispanic/Latino?
Marital Status (opti on al):
[
Yes
Slngle
f
E
f
Married
I
Day
Year
Other
wo
Regardlessof your answer to the previous question,pleaseindicate how you identify yourself.
American Indian or Alaska Nativc (including all Original Peoplesof the Americas)
Asian (including subcontinentanclPhilippines)
I
f
f
elack or African American (including Africa and Caribbean)
f
Native Harvaiian or Other Pacific Islander (Original Peoples)
Q
White (including Middle Eastern)
Citizenship
Are you a citizen or permanent resident of the UnitedStates?
I
Yes D N o
If no, what is the country of your citizenship?
Visa Type
What is the countrvof vour birth?
Visa No.
Plans
Enrollment
When do you wish to beginyour studiesat SNHU? f]
Will you pursueyour studieson a: I
Ealt20-
Full-timebasis
Do you intendto applyfor FinancialAid?
f
Yes
Spring20-
f
Summer20-
Part-timebasis
f
D
f
No
ma)tbetaught
Please
note:AII courses
somecourses
maybeavailable
in a hybrid
college
campus.
fully online,although
formatonyourcommunity
OFFICIAL USEONLY.DO NOT WRITE IN THIS BLOCK. Community CollegeAuthorization
Thisstudent
is qualified
to applyfor theCCSNH-SNHU
NursingConsortium
agreement. f, Ves E No
Thisstudent
is a NH resident
andcurrentlyenrolled
in CCSNH. I Ves E No
Projected
Completion
Date:
Academic
Advisor
Print Nante
Signature
Print Name
Signature
Regishar
Background
Educational
Haveyou previouslyattendedany college(s)
outsideof ccsNH institutions? f, ves
E No
If yes,which institutions?
Pleasenote:By signingthe releasebelowyou agreeto hatteall ofi.cial transcriptsin the communitycollege!possessionforwarded
fo SrVHU
Youmay be askedto submit transcriptsof any colleges
attended.
Additional
Information
Are you entitledto veterantbenefits?
f
ves ENo
Are you now on activeduty in the U.S.Armed Forces? [
Ifyes, what is your current rate/ratingor paygrade?
Ves
ENo
Yearsin Service
EmployerName
Business
Telephone
Mailing Address
Street nante and ntnnber
City
Director of Human Resources
Do you receivecorporatetuition assistance?f,
State
Zip Code
Fa-x #
Ves
ENo
Program
Comp!etion
andtli$bility
forScholarships
In order to be fully admitted to the BSN degreeprogram at Southern Nerv Hampshirc University, you must successfullygraduate with the
ADN with a GPA o1'2.5or higher and passthe NCLEX nursing examination.Studentsnay enroll in the BSN program at SNHU before
passing the NCLEX examination, but they must passthe examination by the end of tl.refirst course to gain unconditional admission.
Students who do not meet the 2.5 GPA requirement may also be conditionally admitted to the BSN program, but they must meet the
2.5 GPA requirement within their first six credits to gain unconditional admission to the program. Only New Hampshire state residents
currently enrolled in a CCSNH ADN program are eligible for the discounted tuition through this partnership.
(Return
Cedification
thisformto the0fficeoftheRegstrar
atl{HTlandsignbelow.)
NHTI and Southern New Hampshire University give all students, regardlessof sex, race,color, creed or national origin, equal opportunity
for admission and a quality education. This is an ollicial publication of Southern New Hampshire University and is subject to change at
any time. The university reservesthe right to add, withdraw or revise any course,program of study, provision or requirement described
herein. If accepted,I agree to abide by the rules and regulations of Southern New Hampshire University and to pay all expensesincurred
by me. In consideration of the undertaking by NHTI and Southern New Hampshire University to processthis application for admission,
the undersigned agree that any information furnished to Southern New Hampshire University, at any time and regardlessof whether or
not the candidate is accepted as a student at Southern New Hampshire University, including all information and materials of any kind
received by Southern New Hampshire University from any source, or prepared by anyone at its request,shall be completely confidential
and shall not be disclosed to anyone, including the undersigned except that an authorized Official of Southern New Hampshire University
may, in his discretion, for official PurPoses,discloseall or any part thereof to such a person as he may deem advisable.I authorize NHTI to
share educational records, including all official college transcripts, with Southern New Hampshire University up to the enrolling term
indicated on the application. I agreeto abide by all conditions of the partnership between SNHU and CCSNH.
Applicant'sSignature
Date
Parent/Guardian
Signature(ifstudentis under18yearsofage)
Date
$/ nttotu EMAILCoMILETEDFoRMTo: gradadm@snhu.edu