Term to Enter: Select Term Fall 2018 Fall 2019

First Name:   Middle Name:   Last Name:   Maiden Name:

Home Address:
Address:   City:   State:   Zip Code:   Country:

Mailing Address:
Address:   City:   State:   Zip Code:   Country:

(All correspondence regarding admission will be mailed to the address listed above.)

Home Phone:   Cell Phone:   E-Mail Address:

Social Security #:   Belhaven ID:   Date of Birth (mm/dd/yyyy):

Sex: Male   Female

Name of Basic Nursing Education School:   Date of Graduation:

License Number:   State:

Do you have or have you ever had any disciplinary action pending against your license? Yes   No

(You will be required to show proof of current unencumbered licensure.)

Do you have a degree(s) in another discipline? Yes   No

If yes, Degree:   Discipline:   Date Received:

In answering the following questions, you must disclose each instance regardless of whether charges were not filed or were dismissed, you received pretrial diversion, you received a suspended sentence, you were placed on probation, you were acquitted, or you were convicted.

Have you ever been taken into custody, issued a summons, cited, charged, or arrested for the violation of any law, excluding minor traffic violations? Yes   No

Have you ever pled no contest, pled guilty, or been convicted of any felony or misdemeanor charge (or have charges pending) in any state or jurisdiction, excluding minor traffic violations? Yes   No

If you answered yes to either of these questions, please list the violations below.

I have read and understand the following statements.

• My license as a registered nurse shall remain free of disciplinary action.
• If I hold licensure in any health care discipline, it shall be free of disciplinary action.
• Should I become subject to any disciplinary action while enrolled in the program, I must immediately notify the Dean of Nursing.
• I must maintain high scholastic standards, develop competent nursing skills, and exhibit those personal qualities which are necessary for professional nursing practice.
• I possess the physical and emotional skills required by the nursing professional.
• I declare that the information on this application is complete and accurate, to the best of my knowledge.
• I understand that willfully withholding information or making false statements on this application may be used as the basis for denial of admission or for the basis of dismissal if enrolled in the Belhaven University School of Nursing program.
• I hereby make application to the Belhaven University School of Nursing and agree to abide by the regulations and policies of the Belhaven University School of Nursing and to accept responsibility for payment of all billed charges incurred while I am a student.

Applicant’s Signature:   Date (mm/dd/yyyy):

Enter Value of Ten Minus Three

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