EVALUATION REQUEST FORM - NURSING & ALLIED HEALTH PROGRAMS
THIS IS NOT AN APPLICATION FOR THE NURSING OR DMS PROGRAM
REQUIREMENT: (Please check √ if completed)
All Official Transcripts from other colleges attended attached or already submitted to Enrollment.
(Electronic transcripts can be submitted to officialtranscripts@msjc.edu)
Student has met with an MSJC counselor to review: pre-requisite requirements, official transcripts
from all institutions attended, and verification of science courses.
In class verification of science courses, if not taken at MSJC (EXAMPLE: Registration statement, Class
schedule, etc.) As of now, the School of Nursing & Allied Health is accepting online/hybrid courses
ONLY if taken Spring 2020 through Summer 2020 semesters due to “stay at home” policy.
Evaluation Request Form must be submitted by the deadline date listed for application consideration
Counselor Signature Date
***Any incomplete packets will be returned to the student if failure to provide the above***
requested documentation. ***
EVALUATION REQUEST DEADLINES
Evaluate my transcripts to verify program course prerequisites, GPA, and degree requirements for the
following Nursing & Allied Health Program: Check the program you are requesting to be evaluated:
ADN
Evaluations will be accepted:
July 1st - December 1st (For Feb. 1 App)
• April 1st – July 1st (For Sept. 1 App)
Nursing ADN Applications
□ Filing period: February 1 – 15
• □ Filing period: September 1 - 15
DMS
Evaluations will be accepted:
July 1st - December 1st
DMS Applications
□ Filing period March 1 – 15
LVN-RN Transition
Evaluations will be accepted:
April 1st - July 1st
**Nursing LVN-RN Applications**
□ Filing period: September 1-15
**For LVN-RN students: please submit a copy of a current California LVN license with this request form
Student Name: ID#:
Mailing Address: Phone #:
Email:
City State Zip
I understand all pre-requisite coursework must be completed or in progress (final semester). I have
submitted OFFICIAL transcripts from all schools attended to Enrollment Services. I am requesting
evaluation for NAHD program eligibility. I understand this is NOT an Application into any of the above
mentioned Nursing and Allied Health Programs. Once I have received confirmation of eligibility to apply, I
will need to complete and submit an application to the Nursing and Allied Health Department during the
above program application filing period. If evaluation does not have an expiration date, it will expire 9
months after date listed on cover letter.
Student Signature Date
List all Colleges attended:
Comment(s):
FOR OFFICE USE ONLY
□ Course prerequisites completed □ Course prerequisites incomplete □ See enclosed Academic Evaluation
Comments:
Evaluation Completed by: Date:
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