Fillable RN-BSN Program 2020 Application Demographic Information (Columbia Basin College)

Fill Online, Printable, Fillable, Blank RN-BSN Program 2020 Application Demographic Information (Columbia Basin College) Form

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

RN-BSN Program 2020 Application Demographic Information (Columbia Basin College)

On average this form takes 12 minutes to complete

The RN-BSN Program 2020 Application Demographic Information (Columbia Basin College) form is 2 pages long and contains:

  • 0 signatures
  • 4 check-boxes
  • 46 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Columbia Basin College

BROWSE COLUMBIA BASIN 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-BSN Program
2020 Application
Demographic Information
_______________________________________________________________________________________
Last Name First Middle CBC Student ID Number
_______________________________________________________________________________________
Previous Name(s)
_______________________________________________________________________________________
Address City State Zip
_______________________________________________________________________________________
Preferred Phone Number Alternate Phone Number E-mail Address
_______________________________________________________________________________________
Employer (if applicable)
Prior Education
High School:
_______________________________________________________________________________________
Name of School City State Graduation Date
G.E.D.:
If high school equivalency was obtained through G.E.D., state where and when tests were taken.
_______________________________________________________________________________________
Location Date
Associate Degree School of Nursing:
_______________________________________________________________________________________
Name of School City State Graduation Date
Other Colleges/Universities Attended:
Name of College /
University
Location
(City/State)
Dates
Attended
Program or Course of
Study
Degree Earned
Registered Nurse Licensure
Do you hold a Washington State RN License: Yes No
If you answered yes, please provide the following: _____________________________________________
License Number Expiration Date
If you answered no, please indicate the state(s) in which you have RN licensure:
_______________________________________________________________________________________
I have applied for RN licensure in Washington State: Yes No
I certify that the above information is accurate and complete.
_______________________________________________________ ______________________________
Applicant Signature Date
Please send your completed and signed application, your current resume, and a check for the $29 application
fee to:
Columbia Basin College
Student Records, MS-H4
2600 North 20
th
Ave.,
Pasco, WA 99301
For Official Use Only
Admission Index Score: ______________ Cumulative GPA in ADN Courses: ______________
WA State RN License Verified: ☐Yes ☐No
_______________________________________________________ ______________________________
Evaluator Signature Date
Columbia Basin College complies with the spirit and letter of state and federal laws, regulations and executive orders pertaining to civil rights,
Title IX, equal opportunity and affirmative action. CBC does not discriminate on the basis of race, color, creed, religion, national or ethnic origin,
parental status or families with children, marital status, sex (gender), sexual orientation, gender identity or expression, age, genetic information,
honorably discharged veteran or military status, or the presence of any sensory, mental, or physical disability, or the use of a trained dog guide
or service animal (allowed by law) by a person with a disability, or any other prohibited basis in its educational programs or employment.
Questions or complaints may be referred to the Colleges Title IX/EEO Coordinator: Camilla Glatt, Vice President for Human Resources & Legal
Affairs, 2600 N. 20th Avenue, Pasco, WA 99301, telephone (509) 542-5548, email cglatt@columbiabasin.edu
. Individuals with disabilities are
encouraged to participate in all college sponsored events and programs. If you have a disability, and require an accommodation, please contact
the CBC Resource Center at (509) 542-4412 or the Washington Relay Service at 711 or 1-800-833-6384. This notice is available in alternative
media by request.
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-BSN Program 2020 Application Demographic Information (Columbia Basin 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 21 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document