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   TEAS-V Test Score:
(Or date for which you are registered to test.)

Have you ever been admitted, registered, and/or enrolled in any nursing program? Yes   No

IF YES TO THE ABOVE, please complete the following information:

Do you have a LPN or RN license? Yes   No

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. Any official documents must be supplied to the Mississippi Board of Nursing prior to writing for the NCLEX-RN®.

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.

Submit an essay in the textbox below that includes a discussion of your interest in nursing and a personal reflection on how enrollment in a nursing program grounded in Christian principles might facilitate development and practice as a professional nurse. Your essay should be 2,200 to 2,300 characters in length. (Note the character counter. 2,300 characters approximates the number of characters in one page with 1 inch margins, 12 pt Arial, double-spaced type.)
characters left

I have read and understand the following statements.

• If I have been convicted of a misdemeanor or felony, the Mississippi Board of Nursing may not allow me to write for the NCLEX-RN® exam.
• 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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