(* ) 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 Have you withdrawn, been dismissed, or attended but did not complete another Nursing program?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: