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| Program: |
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| First Name: |
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| Last Name: |
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| Address: |
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| Address 2: |
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| City: |
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| Zip Code: |
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| Day Phone Number*: |
enter as 10 numeric digits
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| Evening Phone Number: |
enter as 10 numeric digits
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| What is the best time to call?: |
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| When do you plan on starting?: |
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| E-mail: |
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| Year of High School Graduation/GED Completion: |
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| Highest Level of Education Completed: |
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| Years of Work Experience: |
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| For Nursing RN-to-BSN, B.S.you must have a RN Licence: |
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| For Nursing RN-to-BSN, B.S.you must have a DIP/Certification in nursing? |
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| For Nursing RN-to-BSN, B.S.you must have a GPA of "2.5 - 2.9", "3.0 - 3.4", or "3.5 +" to qualify.
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| Are you also considering studying on campus?: |
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