Welcome to Arkansas State University!

(*) denotes required information.

* Select ALL Campuses you are applying to (HOLD CNTL KEY DOWN WHILE SELECTING MULTIPLE SITES):
(Hold Ctrl button while selecting more than one campus)
* Last Name:
* First Name:
Middle Name:
* Indicate below the type of certifcation (current or in process) and state of certification:. Please send copy of certification to
Brenda Goodwin, PO Box 910, State University, AR 72467
CNA Certficate
If currently enrolled, what is your scheduled completion date (If not applicable, please type in "NA".):
* CNA Expiration Date:
* CNA Certification Number:
* State of CNA Certification:
* Home Phone:
Cell Phone:
* Email :
* Local Address where notification will be sent:
* City:
* State:
* Zip:

NOTE: If your name, address, or phone number changes during your enrollment, it is your responsibility to notify the School of Nursing and the Office of the Registrar in writing of these changes

* 1. Has your CNA certification or any Health Professions licensure (including Nursing or any other Health Profession) ever been disciplined (revoked, suspended, placed on probation, or reprimanded) or voluntarily surrendered in any state or jurisdiction?
Yes No
* 2. Is your CNA certfication and/or license currently suspended, revoked or on probation or reprimanded for any reason?
Yes No
* 3. Have you withdrawn, been dismissed, or attended but did not complete another Nursing program?
Yes No
* If yes, Please list Name of School:

If you marked ‘yes’, you MUST submit a letter of good standing from the director/chair of each nursing program you have attended, withdrawn from, been dismissed from or otherwise not completed Documentation MUST come directly from the Nursing Program attended. Mail to: School of Nursing, Attention: Brenda Goodwin, PO Box 910, State University, AR 72467

* 4. Were you born in a foreign country?
Yes No
If Yes, What country?

If you were born in a foreign country, you must take one of the following tests: 1) Test of English as a Foreign Language (TOEFL) with a minimum TOEFL score of 83 on the preferred internet-based (iBT); 570 on the paper-based test, or 213 on the computer-based test; 2) International English Language Testing System (IELTS) with a score of at least 6.5 and a spoken band score of 7; or 3) Pearson Test of English Academics (PTE) with a score of 56. (For further information and exceptions see Nursing website) Mail to: School of Nursing, Attn: Brenda Goodwin, PO Box 910, State University, AR 72467

5* . Do you speak Spanish proficiently?
Yes No

For special consideration for Spanish proficiency, you will need to mail official scores of theACTFL-OPI (oral proficiency Interview) to: School of Nursing, Attention: Brenda Goodwin, PO Box 910, State University, AR 72467

6*. Have you taken the requried Admission Exam? If no, please see http://www.astate.edu/college/conhp/departments/nursing/
Yes No
*List all colleges, universities, schools, nursing programs, or other institutions attended since high school. Include credits earned and any degrees earned if applicable: College/ University/ School #Credits/ Degree Date