If yes, are you currently licensed / credentialed in a health care career? Give license number, state, and health care career:
Have you ever applied for a licen
se/credential in a health care career and been denied? Yes
_____ No _____
If yes, please explain:
Has your license/credential ever been suspended, revoked, or put on probation? Yes_____ No _____
If you have previously been
licensed or credentialed in a health care career, indicate the status and reason for the current
status of licensure/credential: Suspension
_______________ Probation ______________Inactive ___________________
Attach copies of all state/national licenses/certificates.
Citizenship Statement: I understand that some clinical sites/facilities have rules regarding citizenship. If I am not a US
citizen, I may be unable to complete a specific clinical experience and may be given a different experience if available.
Availability of alternate experiences is not guaranteed. Student initials of understanding:
**If you need to provide additional explanations or information, please add an extra sheet of paper labeled with your
name and student ID.
Do you have any healthcare related work experience? If so, where and how many years?
Admission Testing Information:
Have you taken the HESI A2? Yes _____ No _____Score _____ Name of Institution test was taken: _________________
(copy of score report must be i
ncluded with the application)
If not taken, when are you scheduled to take it?
__________________________ Where: __________________________
NOTE: The test must be within 2 years of application deadline and cannot be retaken within 6 (six) months. If you retake
the test, it is your responsibility to inform the application coordinator to replace the current score.
Criminal Background Check:
If accepted into the nursing program, each student must undergo a criminal background check and drug screen in order to
comply with policies of affiliating clinical practice agencies. It shall be the student’s responsibility to comply with
instructions provided upon acceptance. The background check and drug screen will be at the expense of the student.
Students who do not meet this requirement in a timely manner or whose background and/or drug screen does not meet
agency standards will not be able to start the nursing program. The findings of the criminal background check may
preclude licensure or employment. Individuals with a question concerning this should schedule an appointment with the
nursing department chair as well as contact the Texas Board of Nursing. *If accepted to the Nursing program an
additional Criminal background check will be required through the Texas State Board of Nursing.