Doctor of Nursing Practice Program
Georgia College and State University
School of Nursing
Verification of Graduate Clinical and Practice Hours
Instructions:
The DNP applicant should forward this form to the program director for completion. Once the form is
completed, it should be returned to the applicant, for submission with other supplemental materials.
Student Name (Print or type):_________________________________________________________
First Middle/Maiden Last
Student School ID Number:______________________________________________________
The information below must be completed by the program director
1. Name of University:______________________________________________________________
Program Name:_________________________________________________________________
University Address:_______________________________________________________________
University Telephone:____________________________________________________________
2. Type of Degree Received:
____Masters of Science in Nursing Program
____Post Master’s Certificate Program
3. Area of Concentration:____________________________________________________________
4. Date of Program Completion:______________________________________________________
5. Total number of clinical practice hours in the program (clock hours):_______________________
6. Your signature on this form attests that the above named individual has completed the program
indicated on this document.
Program Director (print name):_____________________________________________________
Program Director (signature):_______________________________________________________
Date:___________________________________________________________________________
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