Clinical Practice Application

Accelerated Bachelor of Science in Nursing

Application for Admission
Name: *

First Name Middle or Maiden Last Name
Any other name that may appear on your academic records:

First Name Middle Name Last Name
Date of Birth: *

Month Day Year
Date
Social Security Number: *

Home Address: *

Street Address
Street Address Line 2
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Phone (home): *

Area Code Phone Number
Phone (cell/other):

Area Code Phone Number
Email address: *
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Employer:
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Work Phone:

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How would you describe yourself?
Gender: *

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Ethnicity: *

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Race: *

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If multi-racial, provide percentage for each category checked:

Percentage

American or Alaskan Native

Black or African American

Hawaiian or Pacific Islander

Asian

White

Accelerated BSN

Application for Admission

Questions? Call 740-826-8038
College Transcript/Transfer Information

Please list all of the colleges you have attended:
College/University Name:
City/State:
Date Started:

Month Day Year
Date
Date Ended:

Month Day Year
Date
Degree Earned:
Major Program:
GPA:
I attended another college
College/University Name:
City/State:
Date Started:

Month Day Year
Date
Date Ended:

Month Day Year
Date
Degree Earned:
Major Program:
GPA:
I attended another college
College/University Name:
City/State:
Date Started:

Month Day Year
Date
Date Ended:

Month Day Year
Date
Degree Earned:
Major Program:
GPA:
I attended another college
College/University Name:
City/State:
Date Started:

Month Day Year
Date
Date Ended:

Month Day Year
Date
Degree Earned:
Major Program:
GPA:

Please submit the $20 non-refundable application fee (payable to Muskingum University) to Muskingum University, Graduate & Continuing Studies, Montgomery Hall 117, 10 College Drive, PO Box 1837, New Concord, Ohio 43762-1837.

Applications without a signature or $20 application fee will not be processed.
I certify that the information provided on this application is complete and correct to the best of my knowledge. I understand that I am responsible for arranging for the forwarding of official transcripts from schools I have attended, and that such transcripts become the property of Muskingum University and will not be returned.
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Accelerated Bachelor of Science in Nursing