THE!APPLICATION!PROCESS!CHECKLIST!
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Official!Transcript!Request!Form!
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_______________________________! _______________________________!
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D#%0!*6!b'4%5!_______________<*2'#/!<02,4'%.!a,+704!___!___!___!-!___!___!-!___!___!___!___!
<'1-#%,40!o_______________________________________!!!!D#%0!________________________!
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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!
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Or electronically at alliedhealth@eastms.edu
Deadline!for!completed!admission!requirements!is!July!1
st
!of!each!year!
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Personal!Information!
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EMERGENCY!CONTACT!INFO R MATIO N !
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Academic!Information*!
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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.!!
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Theresa!Harpole!
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Compliance!Contacts!Statement!
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