Southwestern Oklahoma State University

School of Nursing

Phone: 580.774.3261

Fax: 580.774.7075

nursing@swosu.edu

Application for Admission

Application Materials(PDF)

B.S.N. Application |Admissions Requirement | Directions for Entrance Test | Entrance Test Information | Criminal Record Check | Performance Standards | Performance Standards Agreement Form | Estimated Expenses | Advisement Form | Professor Reference Form | Peer/Co-Worker Reference Form | Employee Reference Form | Application Check Sheet

Date:
Last Name:
First Name:
Middle/Maiden:
Local Address:    
      Street Number and Name
  City
 State
 Zip
  Telephone
 Work
  
Permanent Mailing Address:    
  Street Number and Name
  City
 State
 Zip
  Telephone
    
  E-mail address
 Alternate E-mail address
In case of emergency, list two people that could be notified:
1. Name:
  Relationship:
  Address:
  Phone:
2. Name:
  Relationship:
  Address:
  Phone:
AFFIRMATIVE ACTION COMPLIANCE STATEMENT
This institution, in compliance with Title VI of the Civil Rights act of 1964, Executive Order 11246 as amended, Title IX of the Education Amendments of 1972, and other federal laws and regulations, does not discriminate on the basis of race, color, national origin, sex, age, religion, handicap, or status as a veteran in any of its policies, practices, or procedures. This includes, but is not limited to, admission, employment, financial aid, and educational services.
To comply with guidelines set forth by our clinical sites, all SWOSU School of Nursing students will be required to complete random drug screening. The School of Nursing has contracted with an independent agency to complete the screening. All testing will be completed before the beginning of the clinical experience.
Have you previously made an application to this school of nursing?
  Yes No    
  Date:
  Comments:
 
Are you an RN?    
  Yes No    
Are you an LPN (LVN)?    
  Yes No    
If yes, give permanent License No.:
  State issued:
If RN, list school attended:    
  School Name:
  City:
  State:
If you have ever attended a school of nursing, please complete the following information:
  Nursing School Name:
  City:
  State:
  Date of entrance:
  Date of withdrawal:
  Reason for withdrawal:
     
Date of High School Graduation or GED:
All formal education (begin with most recent, attach additional listings if necessary ):
Date
From:
 Date
To:
 School:
    Location:
    Credit Hours:
    Degree: Major:
Date
From:
 Date
To:
 School:
    Location:
    Credit Hours:
    Degree: Major:
Date
From:
 Date
To:
 School:
    Location:
    Credit Hours:
    Degree: Major:
The following information is required by the Oklahoma Board of Nurse Registration and Nursing Education.
Have you ever been arrested for any offense or convicted of any offense including a deferred sentence within the past five years with the exception of any offense expunged under 63 O.S. 1981 2-410?
  Yes No    
Employment Information:    
A. How many hours per week do you plan to work while in nursing school?
   What type of work?
B. Pleas list previous employment:    
  Employment (start with most recent)
Employer: Address:
From: To: Position:
Employer: Address:
From: To: Position:
Employer: Address:
From: To: Position:
Employer: Address:
From: To: Position:
Is there any additional information you feel pertinent to your consideration for admission? If yes,provide explanation:
I herein make application for admission into the SWOSU School of Nursing.
I declare my intention to enroll in the School of Nursing, Fall 2010.
  Month:  
  Year:  
I understand that the SWOSU School of Nursing admits a limited number of students, and that the Admissions, Promotion, and Retention committee will select the best-qualified applicants with regards to admission requirements.
  Date:    
  I AGREE with the above statement
I DISAGREE with the above statement