ࡱ> ad` CbjbjR>R> =R0T_0T_2 BBBBBVVV8| <V!4FV( 3 3 3 3 3 3 3$58|03uB0!n"0!0!03BB3@4$4$4$0!RBB 34$0! 34$4$F/h0pA!R/23<!4/9!*9 09B0t0!0!4$0!0!0!0!0!0303"60!0!0!!40!0!0!0!90!0!0!0!0!0!0!0!0! X : FOR OFFICIAL USE ONLY | Receiving SOH Staff Name: Date Received: UNIVERSITY OF GUAM SCHOOL OF HEALTH NURSING PROGRAM APPLICATION FOR ADMISSION TO THE NURSING MAJOR LEVEL Please type or print legibly all the information requested in the blank spaces. A completed application form and Worksheet for Placement constitute a complete application packet which must be submitted to the 91첥 and Academic Standards Committee, School of Health by the posted application deadline. Only complete application packets will be reviewed by the 91첥 and Academic Standards Committee. Indicate your Nursing Major:  FORMCHECKBOX  Generic BSN Program (four year program, with or without prior degree)  FORMCHECKBOX  Second Step BSN Program (have an A.D.N. degree/diploma) 1. Name:  FORMTEXT        FORMTEXT        FORMTEXT       Last First Middle 2. Date of Birth (MM/DD/YYYY): FORMTEXT       UOG ID#:  FORMTEXT       3. Home Phone:  FORMTEXT       Work phone:  FORMTEXT       Cell phone:  FORMTEXT       FORMTEXT  4. Email address:  FORMTEXT       5. Mailing Address:  FORMTEXT       6. Emergency Contact: Indicate full name, relationship to you, and telephone number(s):  FORMTEXT       FORMTEXT  7. If you have a nursing license, please indicate the type (i.e. RN, LPN), issuing state, license number:  FORMTEXT       8. Have you ever been charged or convicted of a felony?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, please explain:  FORMTEXT       9. Have you ever been charged or convicted of a misdemeanor?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, please explain:  FORMTEXT       10. Have you ever had a nursing or other professional license, certificate, or registration limited or revoked OR have you ever been professionally disciplined or placed on probation?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, please explain: FORMTEXT       11. Do you currently engage in drug-related behavior, including the use of mood-altering drugs/substances and/or alcohol that would affect your functional ability to perform while working as a student nurse?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, please explain: FORMTEXT       12. In the last two years, have you ever been treated for a chemical or alcohol dependency?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, please explain: FORMTEXT       13. Have you had any health-related work experience before coming to nursing school (i.e. work as nurse's aid, a medical receptionist, etc.)? 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F H \ ^ ` b d f h j l »~yl~~»jhk35>*U hk35>*jhk35>*Ujhp9z>*Uj.hh>*Uhh>*jhh>*Uhr hegh. h>*jhqP>*Ujh 3}h 3}>*Uh 3}h 3}>*jh 3}h 3}>*Uh. h 3}>*(   024HJLNPRTVXZ\b︱ͣͣ heghojjh>*Ujh>*Ujh>*Uhr hegh. h>*jhh>*Ujhp9z>*Ujhh>*Uhh>*jhh>*Uh3\d~r~iN$ h)0*h1$7$8$H$^ha$gdk35$ h0*1$7$8$H$a$gdr$ )0*hd1$7$8$H$^ha$gdXf$ h)hd1$7$8$H$^ha$gdk35 h0*d1$7$8$H$gdr$ h)0*d1$7$8$H$a$gdo$ h0*d1$7$8$H$a$gdr`bdfhxz|~<@Pz|~㵭jhk35h>*Uhhk35h.>*jThk35h>*Uhk35h>*jhk35h>*UjhZe>*UmHnHujhZe>*U hZe>*jhZe>*Uh.hrho hegh.2:<>HJfhjprDFHdfhp¾¾¾jhp9zU hk35>*j&hk35h>*Uhk35h>*jhk35Uj>hp9zUhk35jhk35Uhh. hegh.hrhohk35h.>*jhp9z>*Ujhk35h>*U2prtvxzԸ޴{j hk35>*Ujn hk35Uj hp9zUhhXfhoh.5\hohrjhp9z>*Uj hk35>*U hk35>*jhk35>*Uh. hegh.j hk35Ujhk35Uhk350&"zX88d$ h|)0*h1$7$8$H$^ha$gdk35$ v)0*h1$7$8$H$^h`a$gdXf$ h0*1$7$8$H$a$gdXfo g$ h0*1$7$8$H$a$gdXf$ h)0*h1$7$8$H$^ha$gdk35$ h)0*1$7$8$H$a$gdr  "$&(*,0 "@LNPRfhjʳʫʞʫrjB hk35>*U\ hk35>*\jhk35>*U\ h.\ h^rh.j hk35U\h 3}h.\jX hp9zU\jhk35U\ hk35\h.hohXfhhk35h.>* hk35>*jhp9z>*Ujhk35>*U+jlnprtvxz|~02468PRTV^`bd|~ƿtj hk35hk35>*Uhk35hk35>*jhk35hk35>*Uj. hVCUj hVCUhVCjhVCUh hegh.h 3}h.\hach.\hohXfh. hk35>*\jhk35>*U\jhp9z>*U\)888 8"8$8,8.808J8L8N8P8R8X888888888888888889饕鋋饃| heghwThk35h.>*jhZe>*Ujhk35hk35>*Uhk35hk35>*jhp9zUjhp9zUjhk35UUhhohXf hegh.hk35 hk35>*jhk35hk35>*Ujhp9z>*U0  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, describe work experience:  FORMTEXT       14. Is English your first language?  FORMCHECKBOX Yes  FORMCHECKBOX  No 15. Are you the first generation of your family to attend college?  FORMCHECKBOX  Yes  FORMCHECKBOX  No 16. Describe at least two future nursing career goals/plans you would like to achieve  FORMTEXT       By my signature below, I certify that the information provided in this application are true and correct. I authorize the University of Guam School of Health, Nursing Division to investigate any or all statements made herein. I am aware that the UOG, Nursing Division has the right to report any legal and/or substance related issues to the legal authority as set forth in the UOG Student Policy and to the Guam Board of Nurse Examiners. It is my understanding that completion of this Nursing Program does not guarantee permission to take the National Council Licensure Examination (NCLEX) to secure a license to practice as a nurse. Applicant's Signature: ____________________________________ Date: ___________________________ A letter will be mailed to you regarding your admission status into the School of Health BSN Program.  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