Southwestern Oklahoma State University

School of Nursing

Phone: 580.774.3261

Fax: 580.774.7075

nursing@swosu.edu

RN Application for Admission

Application Materials(PDF)

Information Letter | Application | Professional Peer Reference | Employee Reference| Degree Course Requirement | Estimated Expenses | Criminal Record Check

Date:
Last Name:
First Name:
Middle/Maiden:
Email Address:
Local Address:    
      Street Number and Name
  City
 State
 Zip
  County
  
  Telephone
 Work
 Cell
Permanent Mailing Address:    
  Street Number and Name
  City
 State
 Zip
  Telephone
    
In case of emergency, list two people that could be notified:
1. Name:
  Relationship:
  Address:
  Phone:
2. Name:
  Relationship:
  Address:
  Phone:
Have you ever before made an application to this school of nursing?
  Yes No    
  Date:
  Comments:
 
Are you an RN?    
  Yes No    
If yes, give permanent License No.:
  State issued:
If you have ever attended any school of nursing, give the following information:
  Nursing School Name:
  City:
  State:
  Date of entrance:
  Date of withdrawal:
  Reason for withdrawal:
All formal education after high school:
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:    
  Please 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, give explanation:
I herein make application for admission into the nursing major at Southwestern Oklahoma State University.
I declare my intention to enroll in the nursing major
  Month:  
  Year:  
Further, I stipulate that it is my intention, if accepted into the nursing program, to enroll as the following type of student.
  Full-Time Part-Time  
I understand the School of Nursing of Southwestern Oklahoma State University admits a limited number of students due to available resources and/or faculty, and although I may meet or exceed the minimum requirements for admission, circumstances may prevent the School of Nursing from admitting all students who have met the admission criteria.
  Date:  
  I AGREE with the above statement
I DISAGREE with the above statement		  
AFFIRMATIVE ACTION COMPLIANCE STATEMENT
This institution is 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 and 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.