THE!APPLICATION!PROCESS!CHECKLIST!
£ ! STEP!1!
_*! %*! 5%%(BHH>>>;0#$%+$;03,H!#-3!$0/02%! %50!g]((/.! a *>qh!/'-Z!%*!$,7 + '%!#-!*-/'-0!#((/'2#%'*-!6*4!#3+ '$$'*- !
%*! "#$%! &'$$'$$'(('! )*+ + ,- '%.! )* //010;! ]220(%#-20! %*! "#$%! &'$$'$$'(('! )*++,-'%.! )*//010! 3*0$! -*%!
1,#4#-%00! #220(%#-20! %*! %50!^GaAFa! %4#2Z;! ^0%%04$! *6! (0-3'- 1 ! #22 0 (% #- 2 0 ! >'//! 2*+0! 64*+!%50!D'402%*4!*6!
a,4$'-1!#-3!]//'03!E0#/%5;!
£ STEP!2!
T'//! *,%!#-!#((/'2#%'*-!6*4!%50!<25**/!*6!a,4$'-1!['-2/,303!'-!%5'$!(#2Z0%\;!?5'$!#((/'2#%'*-! $5*,/3!70!40%,4-03!
%*!%50!]//'03!E0#/%5!]3+ '- '$%4#%'=0!]$$ '$%#-%;!& #Z0!$,40!%*!'-2/,30!#!2*(.!*6!^Ga!/'20-$0!#-3!VU!204%'6'2#%'*-;!
£ ! !STEP!3!
F0@,0$%! %4#-$24'(%$!70!$0-%! %*!"&))!64*+!#//!*%504!03,2#%'*-#/! '-$%'%,%'*-$! .*,!5#=0!#%%0-303!A!%5'$!'-2/,3 0 $!
5'15! $25**/;! [?4#-$604! F 0@,0$%! T*4+! '-2/,303! '-! %5'$! (#2Z0%\;! ! &#Z0! $,40! .*,! 40@,0$%! %4#-$24'(%$! 64*+! #//!
$25**/$!#%%0-303;!
£ STEP!4!
&#Z0!$,40!.*,4!])?!$2*40$![+'-'+,+ !2* + ( * $'%0!$2* 40!IO\!#40!*-!6'/0!'-!%50! #3 +'$$'*-$!* 66'20!*4! $2503,/0! #-3 !
%#Z0!.*,4!])? !706*40 !%50!30#3/'-0;!
£ ! STEP!5!
]6%04!%50! 30#3/'-0!.*,! >'//! 70!-*%'6'03! '6! .*,!5#=0! 700-!$0/02%03!6*4! (0-3'-1!#3 +'$$'*-;!V6!.*,!#220(%!#! $/*%!'-!
%50! (4*14#+8! .*,! >'//! 70! $0-%! #-! '-6*4+ #%'*- ! (#2Z0%! %*! 2*+ ( /0%0;! "&) ) ! 3*0$! -*%! Z00( ! #! >#'%! /'$%! 6*4!
#3+'$$'*-;!V6!.*,!#40!-*%!25*$0-!6*4!%50!(4*14#+ 8!.*,!>'//!5#=0!%*!40#((/.!%50!-09%!%'+0!#!2/#$$!$%#4%$;!V%!'$!
.*,4! 40$(*-$'7'/'%.! %*! 70! $,40! %5#%! #//! *6! .*,4! (#(04>*4Z! '$! *-! 6'/0! (4'*4! %*! %50! 30#3/'-0;! F0+0+7048! k,$%!
702#,$0!.*,!40@,0$%!#!3*2,+0-%!%*!70!$0-%!%*!"&))!3*0$!-*%!+0#-!%5#%!'%!>#$!#2%,#//.!$0-%!*4!4020'=03;!
Official!Transcript!Request!Form!
G/0#$0!$0-3!#-!*66'2'#/!2*(.!*6!+.!%4#-$24'(%!%*!%50!#3340$$!2502Z03!70/*>;!
V6!.*,!( /# - !%*!#%%0- 3 !%5 0 ! <2**7#!)#+(,$8!&04'3'#-!a#=.!b#$0!"9%0-$'*-8!*4!&#2*-!"9%0-$'*-!,$0!%5'$!#3340$$B!
"#$%!&'$$'$$'(('!)*++,-'%. !)*//010!C66'20!*6!]3+'$$'*-$!G;C;!b*9!IJO!<2**7#8!&<!MNMJO
PPKAQRPAOQQK
V6!.*,!(/# -!%*!#%%0 - 3 !%50!_*/30-!?4'#-1/0!)#+(,$!*4!)*/,+7,$!]'4!b#$0!"9%0-$'*-!,$0!%5'$!#3340$$B!
"#$%!&'$$'$$'(('!)*++,-'%. !)*//010!C66'20!*6!]3+'$$'*-$!G;C;!b*9!IXX!&#.50>8!&<!MNRJM
PPKAKQMAINXX
_______________________________! _______________________________!
^#$%!<25**/H)*//010!]%%0-303!! ! D#%0!*6!]%%0-3#-20!*4!_4#3,#%'*-!
a#+0_________________________________________________________________________!
[G/0#$0!,$0!- #+0!.*,!> 04 0!0- 4* //03 !,- 30 4\ !
<%,30-%f$!),440-%!]3340$$__________________________________________________________!
!!!![a,+7 04 !*4!< %400 %\! !!!!![)'%.\!! ! [<%#%0\!!! [r'(\!
<%,30-%f$!"+#'/!]3340$$___________________________________________________________!
D#%0!*6!b'4%5!_______________<*2'#/!<02,4'%.!a,+704!___!___!___!-!___!___!-!___!___!___!___!
<'1-#%,40!o_______________________________________!!!!D#%0!________________________!
G/0#$0!$0-3!%4#-$24'(%B! V++03'#%0 /. ! ]6%04!14#30$!#40!(*$%03! ]6%04!14#3,#%'*-!!
a*%0B!C-!5'15!$25**/!%4#-$24'(%8!(/0#$0!$5*>!3#%0!*6!14#3,#%'*-8!])?H!<] ? !$2* 40$8!#- 3 !(4'-2 '(#/f$!$'1- #% ,40;!
mmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmmm!
Do!Not!Mail!This!Form!Back!To!EMCC.!Complete!It!And!Mail!To!Last!School!Attended.!Make!Sure!You!
Send!The!Appropriate!Transcript!Fee!With!This!Request.!Athletes!Must!Provide!Transcripts!from!All!
Colleges!Previously!Attended.
NURSING!DEPARTMENT!APPLICATION!
LPN!to!RN!Transition!Track!
G/0#$0!40%,4-!#((/'2#%'*-!%*B!
a,4$'-1!D0(#4%+0-%!s^Ga!%*!Fa!
"#$%!&'$$'$$'(('!)*++,-'%.!)*//010!
G;C;!b*9!IXX!
&#.50>8!&'$$'$$'(('
!MNRJM!
[PPK\ KQMAINIX
Or electronically at alliedhealth@eastms.edu
Deadline!for!completed!admission!requirements!is!July!1
st
!of!each!year!
G^"]<"!?nG"!CF!GFVa?!!
Personal!Information!
a#+0Boooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooo!
!!!!!!!!!!!!!!!^#$%!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!T'4$%!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!&'33/0!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!&#'30-!
<*2'#/!<02,4'%.!a,+704Booooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooo!
]3340$$B!oooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooo!
<%400%H](%;!tH!G;C;!b*9!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!)'%.!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!<%#%0!!!!!!!!!!!!!!!!!!!!!!!!!!!!!r'(!)*30!
"+#'/!#3340$$Booooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooo!
?0/0(5*-0!t[$\B!E*+0ooooooooooooooooooooooooooooooooooo)0//oooooooooooooooooooooooooooooooooooooooo!
EMERGENCY!CONTACT!INFO R MATIO N !
a#+0!ooooooooooooooooooooooooooo!!F0/#%'*-$5'(!ooooooooooooooooooo!)*-%#2%!-,+704!oooooooooooooooooooo!
]3+'$$'*-!G # 2Z0%!
Academic!Information*!
E'15!<25**/!]%%0-303!oooooooooooooooooooooooooooooooooooooo!_4#3,#%'*-!D#%0!ooooooooooooo!
<25**/!]3340$$8!)'%.8!<%#%0ooooooooooooooooooooooooooooooooooooooooooooooooooooooooooooo!
_"D!?0$%!oooo.0$!!oooo-*!
^'$%!#//!2*//010$!#%%0-303!['-2/,3'-1!"&))\!!
a#+0!#-3!/*2#%'*-!*6!
'-$%'%,%'*- !
D#%0$!#%%0-303!
&#k*4!*4!#40#!*6!<%,3.!
D01400!]>#4303!
]-!*66'2'#/!%4#-$24'(%!64*+!#//!03,2#%'*-#/!'-$%'%,%'*-$!#%%0-303!#-3H*4!_"D!40$,/%$!+,$%!70!+#'/03!%*B
]3+'$$'*-$!
"&))!
G;C ;!b*9!IXX!
&#.50>8!&'$$'$$'(('!MNRJM!
Admission!P a cket!
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! hav e! ha d! m o r e! tha n! o n e! att e m p t! in! any ! nu rs in g! 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 ! app lica tio n ! of! any ! per so n ! wh o ! has ! bee n ! con v icte d ! of! a! felon y ! or! m isd emeano r! or! ha s!
charges!pending!on!such!issues.!!!
I!state!t h a t! th e !f o re g o ing!stat e ments!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__________________________________!
East!Mississippi!Community!College!is!committed!to!assuring!that!the!College!and!its!programs!are!
free! from! discrim inatio n! and ! hara ssment! based ! upo n! race ,! color,! eth nicity,! sex ,! preg na nc y,!
religion,!nationa l!origin ,!disab ility,!ag e,! se xu al! o rienta tion ,!ge nd er! ide ntity ,!ge ne tic!information,!
status!as!a!U.S.!veteran,!or!any!other!status!protected!by!state!or!federal!law.!!
]3+'$$'*-!G # 2Z0%!
?50!6*//*>'-1!(04$*-!5#$!700-!30$'1-#%03!%*!5#-3/0!'-@,'4'0$!401#43'-1!%50!-*-A3'$24'+'-#%'*-!(*/'2'0$B!
Theresa!Harpole!
D'$%4'2%!D'402%*4!*6!E,+#-!F0$*,420$!
G;C;!b*9!IJO8!<2**7#8!&<!MNMJO!
Compliance!Contacts!Statement!
?50!6*//*>'-1!*66'20$!5#=0!700-!30$'1-#%03!%*!5#-3/0!'-@,'4'0$!401#43'-1!%50!-*-A3'$24'+'-#%'*-!
(*/'2'0$B!
C66'20!*6!%50!D'$%4'2%!D'402%*4!*6!E,+#-!F0$*,420$8!G#.4*//!#-3!""C)HC)F!
IJIK!L0+(04!<%400%!
<2**7#8!&'$$'$$'(('!!MNMJO!
PPK;QRP;JKRQ!
C66'20!*6!%50!D0#-!*6!<%,30-%$!S!D'$%4'2%!D'402%*4!*6!F024,'%+0-%!
D'$%4'2%!D'$#7'/'%.!<04='20$!)**43'-#%*4!
ORMI!<*,%5!T4*-%#10!F*#3!
&#.50>8!&<!MNRJM!
PPK;KQM;INRN!
C66'20!*6!%50!"902,%'=0!U'20!G40$'30-%!
?'%/0!VW!)**43'-#%*4!
ORMI!<*,%5!T4*-%#10!F*#3!
&#.50>8!&<!MNRJM!
PPK;KQM;INXX!