Print clearly in blue or black ink. FULL NAME: LAST FIRST MIDDLE OTHER NAMES THAT MAY APPEAR ON ACADEMIC RECORDS: LAST FIRST MIDDLE DATE OF BIRTH: / / MALE: FEMALE: AGE ADDRESS: STREET CITY STATE ZIP CODE MAILING ADDRESS (If your permanent home is outside the area): STREET CITY STATE ZIP CODE PHONE NUMBERS: HOME: CELL PHONE: EMAIL: EMERGENCY CONTACT: NAME RELATIONSHIP PHONE CITIZENSHIP STATUS: US Citizen Permanent Resident F-1Visa Asylum, Refugee Temporary Protected Status other WHAT IS YOUR ETHNIC BACKGROUND (OPTIONAL): Page 1 of 5
EDUCATION AND WORK BACKGROUND: NO YES CIN IF NO (CHECK ALL THAT APPLY) Transfer Second Baccalaureate I have applied to Cal State L.A. for admission for the Semester/Year ARE YOU CURRENTLY ENROLLED AT CAL STATE L.A.: EDUCATIONAL HISTORY List in chronological order all colleges you have attended or are now attending (including Cal State L.A. if applicable). Name of all Colleges and Universities Attended Address Date(s) of Attendance Degree Month Year Month Year WORK EXPERIENCE List all allied health care experience beginning with the present or most recent. Position Employer Address Dates Employed PREVIOUS EXPERIENCE (PLEASE PROVIDE COPY OF RELEASE/DISCHARGE FROM ACTIVE DUTY) Page 2 of 5
Served in the military Dates Active COMPLETION OF PREREQUISITE COURSES Please list all dates, final grades, and campus where each class was taken. If a class is in progress, write IP in the box marked Grade. If you are uncertain as to whether a course will transfer, visit www.assist.org or talk to your college advisor. Admission to the University as a transfer student requires completion of basic subjects (English, Speech, Critical Thinking, and Math) and at least 60 transferable semester units. Contact Cal State L.A. University Admissions in ADM. 101, (323) 343-3901 or email admission@calstatela.edu to ask about the acceptability of the above four courses if you have doubts. Prerequisite Biology 2010 Human Anatomy Physiology (or minimum 4 semester/5 quarter units transfer course w/lab) Biology 2020 Human Anatomy Physiology (or minimum 4 semester/5 quarter units transfer course w/lab) Chemistry 1100 General Chemistry (or minimum 4 semester/6 quarter units college level transfer course w/lab) Term/Year Quarter/Semester Course Campus Grade English 1010 Composition I Microbiology 2010/2020 (minimum 4 semester/6 quarter units transfer course w/lab) Communication 1100 Public Speaking (or CSU A2 GE Certified course) Page 3 of 5
Critical Thinking (not U.S. Gov t. or Intro to Philosophy) Statistics (includes inferential statistics) (minimum 3 semester/4 quarter units) I certify that all information provided in connection with this application is true, correct and complete. Providing false information or omitting required information is fraud and grounds for denial of enrollment or immediate expulsion from the Nursing Program. APPLICANT S SIGNATURE DATE PRINT NAME Please mail this application and all required documentation, including transcripts, to the Cal State L.A. Patricia A. Chin School of Nursing by 5 p.m. Jan. 12, 2018: California State University, Los Angeles School of Nursing/ST 415 Attention: RN-BSN Nursing Application 5151 State University Drive Los Angeles, CA 90032-8171 Or deliver the application paperwork by Jan. 12, 2018 to: Nursing Student Services Office Simpson Tower 415 5151 State University Drive, Los Angeles, CA 90032-8171 Mondays-Thursdays: 9 a.m.-5 p.m. Fridays: 9 a.m.-5 p.m. If you wish to have verification that mailed applications have been received, please send documents by certified mail, which will ensure a delivery confirmation receipt. Page 4 of 5
If there are changes in any of this information after submission, please notify the Patricia A. Chin School of Nursing in writing. You may fax us at (323) 343-6454. If you have any questions, please contact Florita Otto at fotto@calstatela.edu. Last Name (Please print) First Name 1. I am a current Cal State L.A. student: my CIN is 2. I am not a current Cal State L.A. student. I applied to the University for admission on / / 3. I have submitted my completed supplementary application packet to the by 5 p.m. Jan.12, 2018, including: Official transcripts for all college work. One stamped and self-addressed business size envelopes, size 4 1/8 by 9 1/2. Copy of RN License with photo ID (by July 20,2018) Copy of DD214 Certificate of Release or Discharge from Active Duty. (when applicable) 4. I understand that I will be notified of my status for admission in April 2018. 5. I understand I will pay the University Enrollment Deposit before May 01, 2018. 6. I have signed and dated my Supplementary Application for the RN-BSN Program. 7. I have kept a photocopy of this checklist and application for my records. Page 5 of 5
Page 6 of 5