Fillable Nursing Application Form2020 FILLABLE (Seminole State College)

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Nursing Application Form2020 FILLABLE (Seminole State College)

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The Nursing Application Form2020 FILLABLE (Seminole State College) form is 2 pages long and contains:

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  • 0 check-boxes
  • 65 other fields

Country of origin: US
File type: PDF

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LEGAL NAME:
ADDRESS:
State
CELL PHONE:
E-Mail:
US CITIZEN: YES NO
COLLEGE DEGREES HELD:
ADMITTED TO SSC: YES NO
ATTENDED CLASSES AT SSC: YES NO
SSC STUDENT ID # _____________________________
Yes No
Have you ever been enrolled in an R.N. Program?
Yes No
If YES, check type of program:
Diploma Associates Degree
Where:
When:
Have you ever been enrolled in an LPN Program? Yes No
Where:
When:
Number: ________
YES NO
LTC/HH______ LPN_______ PARAMEDIC_______ OTHER_________
6-12 months________ 12-24 months________ >24 months________
ACT within the last five (5) years? Yes No
PO Box 351 Seminole, Oklahoma 74818-0351 (405) 382-9205 (405) 382-9586 fax
Bachelors Degree
HOME PHONE:
I don't Know
Is your major area of study currently listed as "Nursing"?
Middle
Last
City
Zip
First
SEMINOLE STATE COLLEGE
If already licensed, do you wish to choose the Career-Mobility Pathway?
(LPN to RN option)
Year Graduated:
__________
Licensing State:
____________
Nursing Program
APPLICATION FORM
If No, BCIS ID#:
If yes, attach a copy of our results.
For preference points indicate if you have recent Health Care Provider work experience. Documentation must be provided
from the company human resource office on letterhead and must provide your dates of service.
K:Nursing:Application Packets:Application for Adm Pkts: Revised July 2020 Traditional Application
PO Box 351 Seminole, Oklahoma 74818-0351 (405) 382-9205 (405) 382-9586 fax
SEMINOLE STATE COLLEGE
Nursing Program
APPLICATION FORM
Principles of Biology
OR General Biology &
CHEM
1214 1113
Human Physiology
2214 1213
Human Anatomy
2114 1483/93
Microbiology*
2224 1113
General Psychology
1113 1104
YES NO
Have you ever had disciplinary action taken against any health-related license?
YES NO
Have you ever been judicially declared incompetent?
YES NO
Signature: Date:
Signature: Date:
Pre-Nursing
I understand that applicants who are admitted to the program will be required to submit a background check
and a drug screen that meet the specific requirements of the healthcare agencies where clinical learning experiences may
occur. Based on the results of my background check and/or drug screen, the healthcare agencies may not allow my
attendance which will prevent successful completion of the Nursing Program.
Have you ever been arrested or convicted of any offense, including a deferred sentence?
If you answered yes, to questions 15, 16 or 17, please see note and instructions below.
NOTE: The Board of Nursing has the authority to deny a license, recognition or certificate; issue a license, recognition or certificate
with conditions and/or an administrative penalty, or to issue and otherwise discipline a license, recognition or certificate to an
individual with a history of criminal background, disciplinary action on any professional or occupational license or certification, or
judicial declaration of mental incompetence [59 O.S. 567.8]. These cases are considered on an individual basis at the time application
for licensure is made, with the exception of felony convictions. Potential applicants to state-approved education programs, with a
criminal history, may obtain an initial determination of eligibility for licensure or certification from the Oklahoma Board of Nursing for
a fee. The initial determination of eligibility for licensure petition can be accessed at http://nursing.ok.gov/initialdeterm.pdf.
(Oklahoma Board of Nursing, 59 O.S. 567.12)
I verify the above to be correct information. I understand that it is required that I notify the nursing director of any
changes or potential changes to my records including, but not limited to the criminal background check, drug screen
results, certification/license status or any other legal or medical issues that arise after submission.
The following items are pertinent to your application for taking the RN licensure examination upon graduation, but may
not effect consideration for admission to the Nursing Program.
Indicate the grade received for courses completed and check those in which you are currently enrolled:
English Comp I
English Comp II
U.S. History
U.S. Government
Transcripts must be submitted to validate the above information.
K:Nursing:Application Packets:Application for Adm Pkts: Revised July 2020 Traditional Application
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Nursing Application Form2020 FILLABLE (Seminole State College)

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Completed 30 January 2021

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