Master of Science in Nursing Application

Family Nurse Practitioner (FNP) Certificate Program Application
Date

MonthDayYear
Date
Full name

PrefixFirst NameLast NameSuffix
Have your student records been listed under a different name?

NoYes
Please list other name(s) used for student records
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
Email address 1
example@example.com
Email address 2
example@example.com
Best Method to Contact You

Home PhoneCell PhoneEmail 1Email 2
Gender

FemaleMaleNon-BinaryOther
Please write how you identify.
Race

African AmericanAlaskan NativeAmerican Indian/Indigenous AmericanAsianBlackHispanicNative Hawaiian/Pacific IslanderWhiteOther
Please write how you identify.
Ethnicity

African AmericanAlaskan NativeAmerican Indian/Indigenous AmericanAsianBlackHispanicNative Hawaiian/Pacific IslanderWhiteOther
Please write how you identify.
Please select your age range

20 years or younger21-25 years26-30 years31-35 years36-40 years41-45 years46-50 years51-55 years56 - 60 years61 - 75 years76 - 80 years91 years or older
What is your first language?
What is your country of origin?
What is your city and state of residence?
Will you consider yourself an International student?

YesNoUnsure
Military information

Active DutyReserve DutyVeteranMilitary DependentOther
Do you have a Bachelor's degree?*

YesNo
Please specify which Bachelor's degree you hold.
Do you hold a valid unencumbered U.S. Registered Nurse (RN) license?*

YesNo
What is your license number
What is your license state(s)?
Please explain. Please note that you may not be admitted to this MSN program without an earned (equivalent) of a MSN degree.
How many years have you spent working as a Registered Nurse?
Have you earned/hold the equivalent of a Master of Science in Nursing (MSN) degree?*

YesNo
From which academic institution/nursing program did you earn the MSN degree?
Approximate Date 00/00/000 degree was earned.
Do you plan on enrolling in the program on a full-time or part-time basis?

Full-time (9+credit hours)Part-timeUnsure
Do you plan to apply for Federal Funding from WNMU?

YesNo
Which types(s) of financial aid do you plan on applying for?
Do you plan to participate in a tuition reimbursement program through your employer?

YesNo
What is the name of your employer?
Do you currently work as an RN?

YesNo
How many hours a week do you work?

Less than 10 hours/week11 - 20 hours/week21 - 30 hours/week31 - 40 hours/weekMore than 40 hours/week
How did you learn about our Family Nurse Practitioner Certificate Program?

Advertising Specific to Western New Mexico University (WNMU)Colleague/CoworkerFamily/FriendSocial MediaWord-of-MouthOther
For which semester are you requesting admission?*
Letters of Recommendation

Applicants must have three letters of recommendation submitted directly from the authors to the following e-mail address: Nursing.Graduate@wnmu.edu
Upload your goal statement essay here. Instructions are found on the FNP webpage. *

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Upload your recent CV here.*

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Family Nurse Practitioner (FNP) Certificate Program Application