Admission Application-RN to BS in Nursing at EIU

IF YOU ARE A PREVIOUS EIU STUDENT, PLEASE CALL 217 581-7049.

Applying as * Transfer student after completing an ADN Student with a bachelor's in another field of study must go to http://www.eiu.edu/~graduate/forms/admissionform.pdf
Students who already have a BA/BS in another field of study must fill out a graduate student application form for the Office of the Graduate School and the Nursing Application for Post BA/BS Students.
Applying for.... * Spring 2011 Fall 2011 Spring 2012 Fall 2012
Name: Last, First, MI *
Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
County of residence *

separate names by commas
Previous Name on transcripts

separate names by commas
Home Phone * - (###) - ### ####
Email *
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Birth Date * / MM / DD YYYY
Sex * Male Female
Illinois Resident? * Yes No
How Long?
Citizenship * U.S. Citizen Permanent Resident Alien undocumented
Country of Citizenship if reseident Alien (N/A if not) *
In case of Emergency, contact:
Name * First Last
Relationship *
Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Phone - (###) - ### ####
Email
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Optional
Ethnic Origin-The information requested from the next three questions are so that we may demonstrate to federal and state agencies that the institution is in compliance with appropriate regulations. Your response will not affect the admission decision and is optional.

Select one or more race: White Black or African American American Indian or Alaska Native Asian Native Hawaiian or other Pacific Islander Hispanic or Latino: Cuban, Mexican, Puerto Rican, South Central American or other Spanish Culture or origin of race.
Do either parent(s)/legal guardian(s) have a bachelor's (four year) degree? yes no
Have any immediate family members graduated from Eastern Illinois University? yes no
Please indicate which applies. Hispanic Non HIspanic
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Last high school attended or GED *
Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Date Graduated * / MM / DD YYYY
State and license number for current RN license *
Current Employer
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Contact Person/Title *
Phone * - (###) - ### ####
Email *
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List Colleges/Universities attended, beginning with the most recent. If you need more space, please use option at end to upload a word document with the needed information.

College/University Name *
Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Beginning Date * / MM / DD YYYY
Ending Date * / MM / DD YYYY
Degree Earned *
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College/University Name
Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Beginning Date * / MM / DD YYYY
Ending Date * / MM / DD YYYY
Degree Earned
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College/University Name
Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Beginning Date / MM / DD YYYY
Ending Date / MM / DD YYYY
Degree Earned
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College/University Name
Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Beginning Date / MM / DD YYYY
Ending Date / MM / DD YYYY
Degree Earned
Upload a plain word document listing any other colleges/universities you have attended. Please include all relavant information.
Have you ever been dismissed from a program, college or university? * yes no
If yes, please explain.
Have you ever been convicted of or are under current indictment for a felony? * yes no
If yes, please elaborate.
Tell us more about you.
Personal Statement. How will you achieve academic and personal success at Eastern Illinois University? *
Extracurricular activities, honors, or organizations. *
Advanced Degree Interest * MSN-Education MSN-Leadership and Management Clinical/Advanced Certification Not interested
I understand that no action will be taken until a non-refundable $30 check or money order made payable to Eastern Illinois University has been received by the office of the

RN to BS in Nursing Program
600 Lincoln Ave, McAfee 2230
Charleston, IL 61920.

I understand that withholding information requested on this application or giving false information may make me ineligible to the University or subject to dismissal. I certify that the information provided on the application is correct and complete.

Type name *
Date / MM / DD YYYY

Admission Application-RN to BS in Nursing at EIU

Admission Application-RN to BS in Nursing at EIU

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