WNMU-MSN Graduates - Family Nurse Practitioner (FNP) Certificate Program Application
Date
-
Month
-
Day
Year
Date
Full name
Mr.
Mrs.
Miss
Other
Prefix
First Name
Last Name
Suffix
Have your student records been listed under a different name?
No
Yes
Please list other name(s) used for student records
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Cell Phone Number
-
Area Code
Phone Number
Alternate Phone Number
-
Area Code
Phone Number
Email address 1
example@example.com
Email address 2
example@example.com
Best Method to Contact You
Alternate Phone
Cell Phone
Email 1
Email 2
Gender
Female
Male
Non-Binary
Other
Please write how you identify.
Race
African American
Alaskan Native
American Indian/Indigenous American
Asian
Black
Hispanic
Native Hawaiian/Pacific Islander
White
Other
Please write how you identify.
Ethnicity
African American
Alaskan Native
American Indian/Indigenous American
Asian
Black
Hispanic
Native Hawaiian/Pacific Islander
White
Other
Please write how you identify.
Please select your age range
20 years or younger
21-25 years
26-30 years
31-35 years
36-40 years
41-45 years
46-50 years
51-55 years
56 - 60 years
61 - 75 years
76 - 80 years
91 years or older
What is your first language?
What is your country of origin?
What is your city and state of residence?
Military information
Active Duty
Reserve Duty
Veteran
Military Dependent
Other
Do you hold a valid unencumbered U.S. Registered Nurse (RN) license?
*
Yes
No
What is your license number?
What is your license state(s)?
How many years have you spent working as a Registered Nurse?
Please explain. Please note that you may not be admitted to this FNP Certificate program without an earned (equivalent) of a MSN degree.
Do you plan on enrolling in the program on a full-time or part-time basis?
Full-time (9+credit hours)
Part-time
Unsure
Do you plan to participate in a tuition reimbursement program through your employer?
Yes
No
What is the name of your employer?
How did you learn about our Family Nurse Practitioner Certificate Program?
Advertising Specific to Western New Mexico University (WNMU)
Colleague/Coworker
Family/Friend
Social Media
Word-of-Mouth
Other
For which semester are you requesting admission?
*
Submit
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