(*) denotes required information.
* Last Name:
* First Name:
*Middle Name:
*OTHER NAMES BY WHICH ACADEMIC RECORDS MAY BE FOUND
*Indicate type and state of licensure:
LPN LPTN
*State of Licensure:	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
*License Number
*ASU ID#
*Home Phone:
*Cell Phone:
* Email:
* Local Address:
*City:
*State:	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
*Zip:
Permanent Address:(If different from above:)
City:
State:	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip:
*Notification of admission decision should be sent to:(If applicant does not indicate choice, notification will be sent to first address given above.)
Local Address Permanent Address
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 license in 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 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 Have you withdrawn, been dismissed, or attended but did not complete another Nursing program?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 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.
*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)
*5. Do you speak Spanish proficiently?
Yes No
For special consideration, you will be tested by the World Language Department
*Check one of the following (Months since completing LPN program) (IF over 12 months, Documentation of Work Experience must be submitted; see checklist for additional information)
Less 12 Months 12 to 36 months 37 to 60 months More 61 months
*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
	*Validate Image: