Fillable RN Advanced Placement Program Application (Anne Arundel Community College)

Fill Online, Printable, Fillable, Blank RN Advanced Placement Program Application (Anne Arundel Community College) Form

Use Fill to complete blank online ANNE ARUNDEL COMMUNITY COLLEGE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

RN Advanced Placement Program Application (Anne Arundel Community College)

On average this form takes 85 minutes to complete

The RN Advanced Placement Program Application (Anne Arundel Community College) form is 24 pages long and contains:

  • 1 signature
  • 45 check-boxes
  • 315 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Anne Arundel Community College

BROWSE ANNE ARUNDEL COMMUNITY COLLEGE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
RN Advanced Placement
Program Application
Applications available: Rolling Admission Basis
ADMISSION REQUIREMENTS
• First consideration will be given to candidates whose resident address is in Anne Arundel County
for at least three months prior to the date the application is submitted. The Address Verification
form must be submitted with the program application. Out-of-county applicants will only be
reviewed if space is available.
• Attend an Information Session. Please visit http://www.aacc.edu/apply-and-register/credit-
application/health-science-applicants for dates and times. Admission and selection information
will be reviewed.
• Must satisfactorily complete all academic and admission requirements.
• Must have a minimum adjusted grade point average (GPA) of 2.5 at this college.
• Chemistry requirement must be complete by the date the application is submitted.
• Arithmetic Placement Test is required with a score of 27 or better, or MAT 005 with a grade of
C or better at the time application is submitted. Note: You have 2 attempts to achieve a passing
score (27>) on the Arithmetic Placement Test. Arithmetic Placement Test scores must be
within 7 years from the date Health Sciences program application is submitted. Retake is
allowed if test is past this time frame. One retake is allowed after that if needed. There is no
time limit on MAT 005.
• Test of Essential Academic Skills (ATI TEAS) is required. Individual Performance Profile must
be attached to application. Testing for the ATI TEAS is unlimited; however, the test must have
been successfully passed with a score of Proficient or higher within 2 years of date of
application.
• Official transcripts and/or clinical experience required documents as listed in admission
requirements. Official transcripts are received by AACC in the sending institution’s original
sealed envelope or sent electronically from sending institution.
• Prerequisites with a grade of C or better (with exception of BIO 231/233, which must be a grade
of B or better) in ENG 101/ENG 101A, PSY 111, PSY 211, MAT 137 or higher, BIO 223, and
BIO 232 or BIO 234, which must be completed by the date the application is submitted.
Pass/Fail grades are not accepted.
• Science courses (except chemistry) must be taken within 7 years of time the application is
submitted.
• A grade of C or better is required in NURS 159. NURS 159 must be taken the semester prior to
starting the nursing course sequence. NURS 159 is a 6-credit online 16-week course through
the American Public University System (APUS). AACC will notify APUS of selected students.
APUS will then contact student to set up registration.
• In the event there are more qualified applicants than seats available, qualified applicants not
initially selected for conditional acceptance will be placed on a waitlist. If applicant declines the
seat, he/she will need to reapply for a future seat. In the event that we do not have enough
qualified applicants, qualified applicants who do apply will be rolled into the following semester.
Final acceptance in the program shall be contingent upon class seat availability, satisfactory
completion of a criminal background check and a health examination record, and submission of a
copy of the required CPR card. A grade of C or better is required in each Registered Nursing (NUR)
course to progress in the program.
IMPORTANT INFORMATION
1. Direct all inquiries regarding the application process to the Health Sciences Admissions office
via email at tdneall@aacc.edu.
2. If you are submitting an application and have not yet attended a nursing information
session, plan to attend a session. You may visit https://www.aacc.edu/calendar/. for dates and
times of nursing information sessions.
3. All Health Sciences students who are offered admission and/or clinical placement will be
required to submit to a complete criminal background check and urine drug screen. All student
applicants’ final acceptance in the program shall be contingent upon satisfactory completion of
a criminal background check and a urine drug screen.
All letters of acceptance shall state that the acceptance is conditional and contingent on
submission of a criminal background check and urine drug screen—as may be required by the
program—that results in satisfactory reports. If an accepted student tests positive for an illegal or
un-prescribed drug, the student shall be denied admission or terminated from any Health
Sciences program.
Separate, additional criminal background checks and urine drug screens may be required by
clinical sites prior to placements. Students with an unsuccessful background check or urine
screening who are denied by a clinical site that is required to meet program competencies shall
be dismissed from the program and their registrations shall be withdrawn from courses related to
the program of study. If the student tests positive for an illegal or un-prescribed drug, the student
shall be denied admission or terminated from any Health Sciences program even if a denied
placement was not required to meet program competencies. Successful reports of criminal
background checks and urine drug screens do not assure eligibility for specific clinical site
placement, program completion, and/or eligibility to sit for professional licensure/board
examinations.
Students are reminded that licensing boards for certain health care occupations and professions
may deny, suspend, or revoke a license or may deny the individual the opportunity to sit for an
examination even if the individual has completed all program course work if it is determined that
an applicant has a criminal history or has been convicted of, or pleads guilty, or pleads nolo
contendere or the like to a felony or other serious crime.
Successful completion of a Health Sciences program of study at Anne Arundel Community
College does not guarantee licensure, the opportunity to sit for a licensure examination,
certification or employment in the relevant health care occupation.
Students may be automatically denied admission or, if enrolled, dismissed from the program if
they have not been truthful or have provided inaccurate information on the application or on any
other form or submission. Students who have questions or concerns are encouraged to contact
the Health Sciences Admissions Office at healthsciencesadmissions@aacc.edu.
*Notwithstanding the statements herein regarding urine drug screens, as of September 2010,
only certain programs will be requiring drug screening. AACC shall inform students which
programs presently require them. However, AACC, at any time, has the right, upon notice, to
require any and all students and any and all programs to comply with drug screening.
MINDER: Students who have been convicted of a felony or a misdemeanor may not be
eligible for licensure as a registered nurse. These students are required to contact the Maryland
Board of Nursing at 410-585-1900
LPN, Paramedic, Veterans to RN
Advanced Placement
ROLLING ADMISSIONS
PROGRAM APPLICATION
Check program applying to
☐
LPN to RN
☐
Paramedic to RN
☐
Veterans to RN
Students are admitted on a rolling admission basis. Incomplete applications will be returned to the student
and can be resubmitted only after they are complete. Students need only apply once to the program, providing their
application is complete. A future seat will be slotted once the applicant meets the criteria for admission.
If you have previously submitted your official transcript(s) to Records and Registration at AACC, it is your
responsibility to ensure that the transcript(s) have been posted by the time you submit your application. If the
official transcript(s) are not posted, the application will be considered incomplete and will be returned.
Transcript(s) being submitted to AACC for the first time must be received in the sending institution’s original sealed
envelope or sent electronically from the institution to AACC’s Records and Registration office to be considered official. You
will be notified by the Records Office of any courses that do not transfer as equivalent to coursework at AACC.
Demographic Information
Last Name
First Name
Middle
Address
City
State
Zip Code
Last 4 digits of social
security
#
College ID #
The mailing address you provide on this application will be your address of record. It is your responsibility to notify
the Health Sciences Office as well as the Records Office of name, address and phone number changes during
the
application
process.
Home
Phone
Cell Phone
Work Phone
AACC Email
Address
– Required No other email is acceptable
@mymail.aacc.edu
Applicants
are advised to check their AACC email account periodically for
placement
updates. Qualified
applicants will be issued a letter of conditional acceptance into the upcoming class after your application has been
verified as complete and accurate.
By
signing below, I
agree/understand
the following:
1. I have an active admission status at AACC and am in Good
Standing
(2.5 GPA>) with the college.
2. I have
submitted
final official
transcripts
from ALL
previously attended
colleges and, if needed,
high school transcript
International
students must submit official transcript evaluation report
from ECE,
W
ES or SpanTran to
verify
/authenticate your high school and/or
college
transcripts
if applicable.
3. If
information
is missing from
my
application
or file
(including transcripts),
it will NOT be processed and
will be returned to me. Incomplete applications will NOT be considered.
4. A copy of my additional requested documents are attached to this application including supporting
address verification documents as well as clinical experience forms.
5. A copy of my professional official transcripts and/or clinical experience documentation is attached to
this application.
6. I understand that by filling in my name below, it will be considered my signature.
Signature:
Date
:
CHEMISTRY
You must have completed a
chemistry
course and earned a grade of
C or better prior to submitting an application.
U.S. High School
Chemistry
(1 credit) or CHE 011 (2 equivalent hours) or CHE 103 / 111 / 113 / 115
(3 – 4 credits)
*If from high school, you MUST submit a final official high school transcript to verify successful completion of
this course
If home
schooled,
the high school
curriculum
must be under a
recognized umbrella organization
with the
supervision
of a
state-approved
curriculum. AACC may require a course syllabus so that our chemistry
department chair can review and approve the curriculum
School where you completed the chemistry requirement
:
SEMESTER/Year
:
GRADE:
ARITHMETIC PLACEMENT TEST
This is not the
same
as the
Accuplacer Mathematics Placement
Test
This test may only be taken two (2) times. Failure to achieve a passing score (27 or better) after two attempts
will require completion of MAT 005 with a grade of C or better prior to application. Test must be taken within 7
years from the date the application is submitted. There is no time limit on MAT 005.
APT SCORE:
M
ATH 005 - Must provide official transcript if taken at institution other than AACC
GRADE:
WHERE
TAKEN:
ATI TEAS (Test of Essential Academic Skills)
No limit on the number of attempts to achieve proficient or higher. The test submitted with application
must have been successfully passed within 2 years of date of application submission.
A copy of your ATI TEAS Individual Performance Profile must be attached to application.
MINIMUM
OF 27
COLLEGE CREDITS
with C or better
If you do not have a minimum of 27 college credits at the time of application, you will be required to
provide an *official high school transcript to the Records and Registration office prior to submitting this
application. *Official transcripts are received by AACC in the sending institution’s original sealed
envelope or sent electronically from the sending institution. Transcript must verify date of graduation.
Your application will be considered incomplete without this document and will be returned.
NAME:
.PREREQUISITE COURSES
Must be completed prior to
application
• Biology 231/233 must be completed with a minimum grade of B
• All other prerequisite courses must be completed with a minimum grade of C
• Science courses must be taken within 7 years of time of the application submission date
• A prerequisite cumulative GPA of 2.5 (no rounding) is required.
Due to the selection process, the Registered Nursing program cannot accept Pass/Fail as a
replacement for letter grades in the required courses.
PREREQUISITES GRADE CREDITS
WHERE COMPLETED
TERM AND
YEAR
*Human Biology 1 BIO 231
and
Human Biology 2 BIO 232
OR
*A & P 1 BIO 233
a
nd
A & P 2 BIO 234
MICROBIOLOGY BIO 223
PSY 111
PSY 211
MAT 137 – MAT 145, 151, 191,
or 230 satisfies MAT 137
requirement. (Former MAT
courses 121, 131, 141 or 142 will
also satisfy MAT 137
requirement.)
ENG 101/ENG101A
(Previously completed ENG
111/115 or 121 will be
accepted)
Arts and Humanities
List course ____________
(Previously completed ENG 112
or 116 will be accepted)
GENERAL EDUCATION REQUIREMENTS - Must be completed with a grade of C or
better by the end of the program.
SOC 111
ARTS and HUMANITIES
List course:
BACKGROUND INFORMATION
Submit explanation of questions for which you answer "yes" and provide documents relating to your
answer in a sealed envelope attached to this application. Attention: Tammie Neall
Do not write explanation(s) on the
application.
Yes
☐
No
☐
Were you ever disciplined for any academic or behavior/conduct issue by any college,
university, or any other educational institution after high school including, but not limited to,
probation, dismissal, suspension, disqualification, or imposition of a failing grade as a
disciplinary sanction? If your answer is yes provide a written explanation and all relevant
documents relating thereto.
Yes
☐
No
☐
Have you ever been convicted of a crime, driving while intoxicated or impaired (either by
alcohol or drugs), had your driving privileges suspended or revoked, and/or are there any
pending charges regarding any of the above? If your answer is yes provide a written
explanation and all relevant documents relating thereto.
Yes
☐
No
☐
Have you ever surrendered your driver's license or had such license suspended or revoked?
If your answer is yes provide a written explanation and all relevant documents relating
thereto.
Yes
☐
No
☐
Have you ever surrendered a professional license, certification or registration, or had one
restricted, suspended or revoked? If your answer is yes provide a written explanation and all
relevant documents relating thereto.
Yes
☐
No
☐
Have you ever been placed on professional probation, had conditions or limitations placed
on your ability work even if your license had not been restricted, suspended or revoked? If
your answer is yes provide a written explanation and all relevant documents relating thereto.
Yes
☐
No
☐
Have you ever had your clinical privileges at any office or facility restricted, suspended or
revoked? If your answer is yes provide a written explanation and all relevant documents
relating thereto.
NOTE: Licensing boards for certain health care occupations, including Nursing, may deny, suspend, or revoke a license or may
deny the individual the opportunity to sit for an examination even if the individual has completed all program course work, if it is
determined that an applicant has a criminal history or is convicted or pleads guilty or nolo contendere to a felony or other
serious crime. If applicable, it is recommended to contact the Maryland Board of Nursing for clarification at 410-585-1900.
I certify that the information on this application is true and accurate to the best of my knowledge. Falsification or
misrepresentation of any information on this application may result in being denied admission, or if enrolled,
dismissed from this program. I understand that final acceptance into the RN program shall be contingent upon
satisfactory completion of a criminal background check and satisfactory completion of a health examination record
and CPR certification.
Signature: Date:
PRINT NAME:
Notice of Nondis
crimination: AACC is an equal opportunity, affirmative action, Title IX, ADA Title 504 compliant institution. Call Disability Support
Services, 410-777-2306 or Maryland Relay 711, 72 hours in advance to request most accommodations. Requests for sign language interpreters,
alternative format books or assistive technology require 30 days’ notice. For information on AACC’s compliance and complaints concerning
sexual assault, sexual misconduct, discrimination or harassment, contact the federal compliance officer and Title IX coordinator at 410-777-1239,
complianceofficer@aacc.edu
or Maryland Relay 711.
I understand that by filling in my name below, it will be considered my signature.
ADDITIONAL ADMISSION DOCUMENTS TO BE SUBMITTED AT TIME OF APPLICATION
NOTE: Applications submitted without this documentation will be returned as incomplete.
LPN’s
Official transcript from LPN training must be submitted to verify successful completion of LPN training from a state-approved
licensed practical nursing program.
Clinical Experience
The
following material must be submitted to continue the application process:
•
Official transcript from a state-approved licensed practical nursing program.
•
Copy of current active Maryland LPN license LPN’s must have an active unencumbered Maryland license, in
agreement with the Maryland Board of Nursing and the Maryland Higher Education Commission.
•
Verification of current employment as an LPN for a minimum full-time equivalent (2080 hours) of one year
within the last three calendar
years.
•
Submission of Clinical Experience Form.
•
Submission of Work Performance Evaluation.
Paramedics
Official transcript from Paramedic training must be submitted to verify successful completion of Paramedic training from a
state-approved licensed paramedic program.
Clinical Experience
The
following material must be submitted to continue the application process:
•
Official transcript from a state-approved licensed paramedic program.
•
Copy of an active Maryland Paramedic license. Paramedics must have an active unencumbered
Maryland license from the Maryland Institute for Emergency Medical Services Systems.
•
Verification of current employment as a Paramedic for a minimum full-time equivalent (2080 hours) of one year within
the last three calendar years.
•
Submission of Clinical Experience Form.
•
Submission of Work Performance Evaluation.
Veterans
Clinical Experience
•
Applicants must be a Medic/Corpsman to qualify for this program with at least one year of experience within the last three
calendar years.
•
Submit a copy of your DD-214 (Certification of Release or Discharge from Active Duty) as verification of your required
medical service.
G:\ALHEALTH\HDrive\AHCOMMON\HS Admin\Tasks\Admssions TDN Tasks\Advanced RN\Advanced RN Application5.13.2020.docx
LPN or PARAMEDIC CLINICAL WORK EXPERIENCE FORM
Applicant’s Name:
What program are you applying to:
☐
LPN
☐
PARAMEDIC
(Not necessary for Vet to RN applicants)
Verification of current employment as an LPN or Paramedic for a minimum full-time equivalent (2080
hours) of one year within the last three years. Start with the most recent employment.
* Account for any lapse in employment.
Note: A separate Work Performance Evaluation must be submitted by each agency representing work
experience/hours.
AGENCY:
UNIT:
POSITION:
SUPERVISOR’S NAME:
TITLE:
EMPLOYED FROM:
TO:
HOURS WORKED PER WEEK:
DUTIES PERFORMED:
AGENCY:
UNIT:
POSITION:
SUPERVISOR’S NAME:
TITLE:
EMPLOYED FROM:
TO:
HOURS WORKED PER WEEK:
DUTIES PERFORMED:
AGENCY:
UNIT:
POSITION:
SUPERVISOR’S NAME:
TITLE:
EMPLOYED FROM:
TO:
HOURS WORKED PER WEEK:
DUTIES PERFORMED:
AGENCY:
UNIT:
POSITION:
SUPERVISOR’S NAME:
TITLE:
EMPLOYED FROM:
TO:
HOURS WORKED PER WEEK:
DUTIES PERFORMED:
VERIFICATION OF LPN OR PARAMEDIC TRAINING
NAME OF SCHOOL
ADDRESS OF SCHOOL
DATE OF GRADUATION
DO YOU HAVE A MINIMUM OF 2080 HOURS WORKED AS AN LPN or PARAMEDIC WITHIN THE LAST
THREE YEARS?
YES NO
MUST ATTACH A COPY OF YOUR CURRENT ACTIVE MARYLAND UNENCUMBERED LICENSE
I CERTIFY THAT THE INFORMATION ON THIS FORM IS TRUE TO THE BEST OF MY KNOWLEDGE.
Applicant’s signature Date
NOTE: Successful completion of an approved LPN refresher course may satisfy the clinical experience requirement.
I CERTIFY THAT THE
INFORM
ATION ON THIS FORM IS TRUE TO THE BEST OF MY KNOWLEDGE.
Applicant’s Signature Date
ANNE ARUNDEL COMMUNITY COLLEGE
DEPARTMENT
OF NURSING
Arnold, Maryland
LPN/PARAMEDIC
WORK PERFORM ANCE EVALUATION
*Must be received in a sealed company envelope and submitted with your application.
I. STUDENT RELEASE OF INFORM ATION
I
hereby
give
permission
for
(
NAME OF AGENCY)
to release the information requested by the Anne Arundel
Community
College, Department of Nursing regarding
m
y work
performance
on
(NAME OF UNIT)
from
the
dates
of
to
I hereby give permission for the Department of Nursing, Anne Arundel Community College to contact the above agency
or
representative
if additional information is needed.
(Print name) (Former or maiden name)
Signature Date
II. SUPERVISOR:
This applicant has applied to Anne Arundel
Community
College RN Advanced Placement Program leading to an
Associate Degree in Nursing and
eligibility
for RN Licensure. As part of the admission criteria, a work performance
evaluation is required.
Please complete this confidential evaluation and return it in a sealed company envelope to the applicant.
This form must be attached to the program application at the time of application submission.
NAME OF STUDENT:
NAME & ADDRESS OF AGENCY
:
EMPLOYED FROM:
TO:
NAME OF UNIT:
TYPE OF UNIT (eg. MED/SURG/PEDS/ICU/ER)
TITLE OF POSITION OF EMPLOYEE:
AVERAGE NUMBER OF HOURS WORKED PER WEEK:
BRIEF DESCRIPTION OF DUTIES:
NAME OF SUPERVISOR: TELEPHONE #
III. EVALUATION BY SUPERVISOR
Employee Name:
Please indicate your
evaluation by number in the space to the right of the statement, according to the rating
scale described below:
5
Excellent
4
Above Average 3 Average
2
Needs Improvement
Professional Behavior:
RATING:
Punctual
Presents professional appearance according to dress code
Maintains professional confidentiality
Practices within ethical and legal standards of care
Able to identify self-strengths and areas for improvement
Adheres to agency policies/procedures
Respects the opinions and rights of others
Application of the Nursing Process when performing patient care:
Assessment/analysis
Planning
Implementation
Evaluation
Management of Patient Care:
Organizes and completes patient care on at least one patient in a timely manner
Identifies and acts upon priorities of care
Implementation of Nursing Care
Safely administers prescribed treatments and medications
Maintains patient safety while providing physical care
Demonstrates
safety while performing
psychomotor
skills
Psychomotor Skills – competency in:
IV monitoring
NGT/GT feedings
Sterile fields
Complex dressing changes
Oral medications
IM medications
SQ medications
Communication Skills:
Communicates effectively with the health team
Establishes therapeutic relationships
Reports significant data to the appropriate health team members
Documentation of Care:
Documents pertinent data
Uses appropriate medical
terminology
consistently
Follows agency guidelines for documentation
Any additional comments:
Signature: Title: Unit:
Telephone : Agency: Date:
Please return with the program application.
101 College Parkway Arnold, Maryland 21012-1895
Records and Registration Office / SSVC 140
410-777-2243 / Fax 410-777-2489 / records@aacc.edu / www.aacc.edu/recreg / MyAACC http://myaacc.aacc.edu
PERMISSION TO STUDY AT ANOTHER INSTITUTION
If you are an Anne Arundel Community College (AACC) student and wish to enroll in a course(s) at another institution and transfer those
credits back to AACC, please complete this form. When completed, the form must be returned to the AACC Records Office at the Arnold
Campus along with the course description(s). Your course(s) will be reviewed for transferability and a completed copy of this form will be
mailed to your address within five business days. An official transcript of the coursework must be sent to the Records Office at AACC after
the courses are completed at the designated institution. This permission is only applicable to the course(s) and the semester indicated below.
If you do not complete the course(s) within the semester indicated, you must submit a new request.
Student Information
Name AACC ID#
Last First MI
Address
Street City State Zip code
Email address Daytime Phone
Program of Study (Major) at AACC
Check this box if you would like to have a copy of the completed form forwarded to the Financial Aid and Veterans Affairs Office at
Anne Arundel Community College.
Course and Institution Information
Name of institution where course(s) will be taken:
American Public University System (APUS)
Semester/year course to be completed:
Course(s) requested to be taken at above institution:
Department & Course Number
Course Title
Credits
NURS 159
Fundamentals, Adult, and Childbearing Family Nursing Transition Course
6
Certification of Transferability to AACC (Records Office Use Only)
Course
N
umber
at Above Institution
Equivalent Course at AACC
Credits Accepted
at AACC
Minimum Grade Requirement
for Course
Comments:
Records Initials Date:
Notice of Nondiscrimination: AACC is an equal opportunity, affirmative action, Title IX, ADA Title 504 compliant institution. Call Disability Support Services, 410-777-2306 or Maryland Relay 711, 72 hours in advance to request
most accommodations. Requests for sign language interpreters, alternative format books or assistive technology require 30 days’ notice. For information on AACC’s compliance and complaints concerning sexual assault, sexual
misconduct, discrimination or harassment, contact the federal compliance officer and Title IX coordinator at 410-777-1239, complianceofficer@aacc.edu or Maryland Relay 711. REV: 3/2020
ADDRESS VERIFICATION
Consideration will be given only to candidates whose verified resident address is in Anne Arundel County for
at least three months prior to the date the application is submitted.
The A
ddress Verification Form is part of the application packet and must be completed in its entirety with the
application. Be sure to include two documents as listed on the form to verify residency. If not selected for the
initial class, the Address Verification form must be resubmitted to the Records Office.
Ques
tions pertaining to this form can be addressed to Melissa Mumma in the Records Office at
410-777-2721.
OUT-OF-
COUNTY APPLICANTS
WILL BE
REVIEWED
ONLY WHEN
SPACE
IS
AVAILABLE.
Revised: May 2020
G:\ALHEALTH\HDrive\AHCOMMON\HS Admin\Tasks\Admssions TDN Tasks\Advanced RN\Advanced RN Application5.13.2020.docx
101 College Parkway, Arnold, Maryland 21012-1895 410-777-2243
ADDRESS VERIFICATION FOR HEALTH SCIENCE PROGRAM APPLICANTS
Directions: This form must be completed entirely and supporting documents submitted as part of the health sciences
program application process. Applications submitted without this document will be returned as incomplete.
If you the student support yourself, provide a minimum of two of the documents listed below in your name, at current
resident address that are dated three months prior to the application deadline date.
OR
If for the most recent 12 months, you, the student, have resided in Anne Arundel County, but are supported by someone in
another Maryland county or state, provide a minimum of two of the documents listed below in your name, at current resident
address that are dated three months prior to the application deadline date.
OR
If for the most recent 12 months, another person(s) has provided one-half or more of your financial support, provide a
minimum of two documents listed below in your supporter’s name, showing current resident addresses that are dated three
months prior to the application deadline date.
In addition, you will need to provide one document from the list below in your name showing current resident address and
dated three months prior to the application deadline date in addition to the two documents from your supporter. The
supporter must also complete the information requested in Section B.
Military Personnel Only:
Complete this form with a copy of your military ID (also dependent ID, if spouse or dependent), copy of orders, and a copy
of housing assignment, lease, deed or utility bill showing your resident address.
Example: All documents must be dated three months prior to application submission date.
Acceptable Documents
• Maryland Driver’s License
• Voter Registration Card
• Copy of Deed of Trust or Signed Lease
• Maryland Withholding Form – MW 507 (Not U.S. W-2)
• Maryland Income Tax Return (not U.S.)
• Utility Bill including gas, electric, water, phone, cable, etc.
• Vehicle Registration Card
The college reserves the right to request additional information and documentation as necessary.
SECTION A – TO BE COMPLETED BY STUDENT
Student Name
Student ID or SSN (last 4 digits)
Resident Address
City
State
Zip
County
Day Phone
Evening
Dates of Occupancy at above address
Own
Rent
Previous Address
City
State
Zip
How long did you live at this previous address?
Are you registered to vote?
Yes
No
County
State
Do you possess a valid driver’s license?
Yes
No
If yes, what state issued?
County
Date of Issuance
OFFICE USE ONLY
Program: Advanced Placement RN
Do you own a motor vehicle? Yes No
If yes, in what state issued? County Date of Issuance
Do you have the use of another person’s motor vehicle? Yes No
If yes, provide name Relationship to student
Are you paying Maryland income tax for this year on all earned income? Yes No
If yes, what county?
List where you have filed tax returns for the past two (2) years:
Year State County
Year S
tate County
If employed, is Maryland income tax currently being withheld? Yes No
If yes, what county?
For the most recent 12 months, has another person(s) provided one-half or more of your financial support?
*Yes No
*If the answer to the above question is “Yes”, SECTION B of this form must be completed by your supporter.
Additional Information
The college reserves the right to request additional information and documentation as necessary.
I CERTIFY THAT THE INFORMATION CONTAINED HEREIN IS CORRECT TO THE BEST OF MY KNOWLEDGE.
Signature of Student (required) Date
OFFICE USE ONLY
ACCEPTABLE DOCUMENTS: MILITARY/BRAC WAIVER:
____ MD driver’s license ____ Military ID (& Dependent ID if spouse or dependent)
____ MD income tax return (not U.S.) ____ Copy of Orders
____ Voter Registration Card ____ Copy of housing assignment, lease, deed or utility bill
____ Vehicle registration showing resident address
____ Utility bill showing home address
____ Copy of deed of trust or signed lease
____ MD withholding form – MW 507 (not U.S. W-2)
STATUS OF RESIDENT ADDRESS
Anne Arundel County Other MD county Out-of-State Term & Year
Authorized signature: Date:
click to sign
signature
click to edit
SECTION B
TO BE COMPLETED BY SUPPORTER IF YOU ANSWERED “YES” to the following questio
n:
For the most recent 12 months, has another person(s) provided one-half or more of your financial support?
Name of supporter Relationship to student
Supporters Address
City State Zip
County Day Phone Evening
Date of Occupancy at above address
Own
Rent
Previous Address
City State Zip
How long did you live at this previous address?
Are you registered to vote? Yes No County
Do you possess a valid driver’s license? Yes No
If yes, in what state issued? County Date of Issuance
Do you own a motor vehicle? Yes No
If yes, in what state issued? County Date of Issuance
Do you have the use of another person’s motor vehicle? Yes No
If yes, provide name Relationship to student
Are you paying Maryland Income tax for this year on all earned income? Yes No
If yes, which county?
List where you have filed tax returns for the past two (2) years:
Year State County
Year State County
If employed, is Maryland income tax currently being withheld? Yes No
If yes, in which county?
Additional information:
The college reserves the right to request additional information and documentation as necessary.
Signature of supporter: Date:
Notice of Nondiscrimination:
AACC is an equal opportunity, affirmative action, Title IX, ADA Title 504 compliant institution. Call Disability Support Services, 410-777-2306 or
Maryland Relay 711, 72 hours in advance to request most accommodations. Requests for sign language interpreters, alternative format books or
assistive technology require 30 days’ notice. For information on AACC’s compliance and complaints concerning sexual assault, sexual misconduct,
discrimination or harassment, contact the federal compliance officer and Title IX coordinator at 410-777-1239, complianceofficer@aacc.edu or
Maryland Relay 711.
G:\ALHEALTH\HDrive\AHCOMMON\HS Admin\Tasks\Admssions TDN Tasks\Advanced RN\Advanced RN Application5.13.2020.docx
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

RN Advanced Placement Program Application (Anne Arundel Community College)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 22 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document