Nursing Application for Post BA/BS Students

This form is for students who have an earned BS/BA and are seeking enrollment in the RN to BS in Nursing Program.

Name: Last, First, MI *
Birth Date * / MM / DD YYYY
Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
County of residence *
Email *
In Case of Emergency
Name, Relationship *
Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Home Phone * - (###) - ### ####
Cell Phone * - (###) - ### ####
Email
Have you ever been dismissed from a nursing program, college or university? * yes no
If yes, provide explanation
Have you ever been convicted of a criminal offense? yes no
If yes, please elaborate.
This form is only the application to the RN to BS in Nursing Program. As a student with a BA/BS, you must also complete and send in the form at http://www.eiu.edu/graduate/prospective_admissions.php for admission to Eastern Illinois University.

Please complete the checklist on the webpage and submit the required documentation.

Name *
Date * / MM / DD YYYY