High School Attended _________________________________________ Graduation Date _____________
School Address, City, State_________________________________________________________________
GED Test ____ yes ____no
List all colleges attended (including EMCC)
Name and location of
* An official transcript from all educational institutions attended and/or GED results must be mailed to
P.O. Box 100
Mayhew, Mississippi 39753
Have you ever been convicted of, pled no contest to, or are charges pending against you for a felony or
misdemeanor in any state/ jurisdiction?
YES ______ NO _______
Have you ever attended nursing school in this or any other program?
Yes ______ NO _______
Please list all schools and dates attended. You must have a letter of good standing from your previous
nursing school Director in order to be considered for this program. You are not eligible for consideration
if you have had more than one attempt in any nursing program.
Have you filled out an application for admission to EMCC within the last 12 months?
Yes ______ No __________. If not, you must apply to the school for admission before being
considered for the nursing program.
Successful completion of the nursing program does not guarantee eligibility to sit for the NCLEX
exam or application for licensure. A Board of Nursing may, at its discretion, refuse to accept the
licensure application of any person who has been convicted of a felony or misdemeanor or has
charges pending on such issues.
I state that the foregoing statements in this application are true and accurate. I am aware that any false,
misleading, or incomplete statements made on this application could be grounds for non-admission to, or
later dismissal from, the nursing program.
Signed _____________________________________ Date____________________________