Nursing RN to BSN Application

Before completing this application, you may want to gather pertinent data. This form is unable to be saved and edited. Once you click submit (or push Enter), the form will be submitted. Information you may want to gather includes: previous college attendance, work experience and an emergency contact.

All fields in bold are required.

General Information
*
Name First Middle Last
Other names used on previous transcripts.
*
Mailing address
Street
City
State
Zip
*
Home phone
Work phone
E-mail
College Education
List any colleges, universities or vocational technical schools you have attended, regardless of duration. Institution 1
Name of institution
Location
Dates attended
Credits earned
Degree earned
Major


Institution 2
Name of institution
Location
Dates attended
Credits earned
Degree earned
Major


Institution 3
Name of institution
Location
Dates attended
Credits earned
Degree earned
Major


Institution 4
Name of institution
Location
Dates attended
Credits earned
Degree earned
Major
Nursing Education
Institution 1
Name of institution
Location
Dates attended
Credits earned
Degree earned
Major


Institution 2
Name of institution
Location
Dates attended
Credits earned
Degree earned
Major

Please click submit when the first portion of the RN to BSN Nursing Application is complete. You will then be directed to the second portion of the form to complete your Application. Once you click Next, you can NOT go back to make changes to a previous section of the form.
Work Experience
(Start with most recent experience.)
List any jobs you have held. Job 1
Place
Title/Description
Position held from to


Job 2
Place
Title/Description
Position held from to


Job 3
Place
Title/Description
Position held from to
Grand View Plans
*
I am admitted to Grand View University. Yes
No
Where and when have you taken statistics?
What semester do you plan on starting the nursing courses?
Registered Nurse
State of Licensure Registration Number
Date of Expiration
Identify any additional states in which you hold licensure (active, inactive)
A copy of your current RN license must be on file and remain updated throughout your career in Grand View’s Nursing Program.
Background Information
Have you ever been convicted of a felony? Yes No
Nursing courses with a clinical component may NOT be taken by a person:
• who has been denied licensure by the board.
• whose license is currently suspended, surrendered or revoked in any U.S. jurisdiction.
• whose license/registration is currently suspended, surrendered or revoked in another country due to disciplinary action.
Optional Information
Social security number
Marital status
Gender Male Female
Date of birth
Ethnic background American Indian/Alaskan Native
Asian
Black or African American
Hispanic/Latino
White
Two or more races
Native Hawaiian/Other Pacific Islander
Other
Person to be Notified in Emergency
Name First Last
Relationship
Mailing Address
Street
City
State
Zip
Home Number
Work Number
Certification
I hereby apply for the nursing program at Grand View University. I state and certify that the information, statements and answers as herein recorded on all application forms are full, true and correct to the best of my knowledge and belief and that no information required to be given therein, either expressly or by implication, has been knowingly withheld. I understand the statements and answers/omissions are a part of this application and, if contrary to fact, could constitute grounds for my dismissal from the nursing program. * Signature

* Date (MM/DD/YYYY)

***NOTE***
Entering your name above is considered a valid signature and signifies your intent to apply for admission to the Grand View University Nursing Department.

Non-Discriminatory Policy
Applicants for admission and employment, students, employees and sources of referral of applicants for admission and employment are hereby notified that Grand View University does not unlawfully discriminate on the basis of age, race, religion, creed, color, sex, sexual orientation, national origin, ancestry or disability in admission or access to, or treatment or employment in, its programs and activities, services or practices. Any person having inquiries concerning the University’s compliance with the regulations implementing Title VI, Title IX and Section 504 of the Rehabilitation Act of 1973 and the Americans with Disability Act is directed to contact the vice president for administration and finance, 263-2821, who has been designated as the equal employment opportunity and affirmative action officer. Any person also may contact the Department of Education, regarding the University’s compliance with regulations implementing Title VI, Title IX and Section 504 of the Rehabilitation Act of 1973 and the Americans with Disability Act.