Doctorate of Nursing Practice APPLICATION CHECKLIST

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1 APPLICATION CHECKLIST 1. A completed online graduate degree seeking application to Washburn University (if not already enrolled at Washburn University). 2. A completed application to the Washburn University. 3. Three (3) Applicant Reference Statements from current or past employers, faculty, or professional peers. 4. Official transcripts of BSN and MSN. 5. Graduate Statistics course transcript (within the last 10 years) with a grade of B or better. 6. Copy of evidence of current licensure in the state of Kansas as a registered nurse and APRN. 7. Evidence of National certification by ANCC or AANP. 8. Current resume. 9. A money order for $60.00, payable to Washburn University as a nonrefundable application fee. Please include all of the above materials in one large envelope. Submit to: Washburn University 1700 SW College Ave. Topeka, KS If you are not a resident of Kansas, contact Dr. Monica Scheibmeir at or by at After your application is received and reviewed, you will be contacted by the to schedule an interview and perform an in-person written assignment.

2 APPLICATION FOR ADMISSION Date of Application:, 20 Fall Admission Deadline: April 1 Spring Admission Deadline: October 1 TRACK APPLYING FOR: (Please select the appropriate track) Adult Gerontology Nurse Practitioner Family Nurse Practitioner APPLICANT INFORMATION within the last 10 years. Last Name: First Name: MI: Maiden/Previous: PERMANENT ADDRESS Street: City/State: Zip: CURRENT ADDRESS ( select if same as Permanent Address) Street: City/State: Zip: Address: Home Phone: Work Phone: Cell Phone: Social Security Number: Military Veteran? YES NO Kansas RN Number: Are you licensed in the state of Kansas as a Nurse Practitioner? YES NO If so, provide your Kansas NP license number: EMERGENCY CONTACT Name: Relationship: Telephone: Street: City/State: Zip:

3 SCHOOL WHERE BSN & MSN WERE ATTAINED: NOTE: Attach official transcripts to this application (along with other application materials) AND send in one envelope addressed to Washburn University, 1700 SW College Avenue, Topeka KS BACHELOR OF SCIENCE IN NURSING College/University: Dates Attended: City/State: Date Degree Conferred: MASTER OF SCIENCE IN NURSING College/University: Dates Attended: City/State: Date Degree Conferred: All qualified applicants for admission will receive consideration without regard to race, color, age, sex, religion, sexual orientation, gender identity, nationality or disability. The University is an equal opportunity institution. THIS SECTION TO BE COMPLETED IN THE PRESENCE OF A NOTARY PUBLIC State of County of Being duty sworn, I state the forgoing statements in this application are true and accurate. I am aware that any false, misleading or incomplete statements made on this application could be grounds for non-admission to, or later dismissal from, the nursing program. Signed: (Applicant s signature) Subscribed and sworn before me this date of, 20 Notary Public

4 APPLICANT REFRENCE STATEMENT TO THE APPLICANT Please print your name: (Last) (First) (Middle) The Family Educational Rights and Privacy Act and its amendments guarantee students access to their educational records. Students may, however, waive their right of access to references. The choice of the applicant regarding this reference is indicated below. Please circle your response: I do / I do not waive my right to inspect the contents of the following reference. Please request reference statements from three persons who have recent knowledge about your qualifications. On the first page of each reference form, fill in your name and give to the references. Ask each of them to send it back to you in a sealed envelope after they have signed across the seal. Send these three unopened references together, with the other application materials, to the. Opened reference letters cannot be accepted. References must not come from a relative. References should be obtained from a current or previous employer, faculty or professional peer. TO THE REFERENCE The above named person is applying for admission to the DNP program at Washburn University, and has given your name as a reference. We seek students who demonstrate potential for graduate academic work as well as commitment to the profession of nursing. Students should demonstrate the following characteristics: critical thinking and decision making abilities excellent verbal and written communication skills ability to analyze, synthesize and utilize knowledge Please provide us a candid assessment of this applicant regarding her/his suitability for our program. You are encouraged to attach a separate letter with this form. When you have completed this reference, please return it to the applicant in a sealed envelope with your signature across the seal. He/she will include this in the application packet.

5 1. How long and in what capacity have you known the applicant? Nature of relationship (employer, co-worker, faculty): 2. What is your estimate of the applicant s potential to be a successful candidate in this DNP Program? 3. Please indicate the applicant s ability and professional competence in comparison to other individuals whom you have known at similar states in their career. EXCELLENT VERY GOOD BELOW N/A Intellectual Capacity Self-reliance, motivation Ability to deal with stress Emotional stability and maturity Critical thinking skills Writing skills Verbal skills Growth potential Skills in relating to others Cultural sensitivity Organizational ability Creativity 5. Other Comments: (Academic abilities, commitment of nursing, values and ethics, emotional stability and maturity, readiness to enter the DNP program.) 4. I would: Highly Recommend Recommend Recommend with reservation Not recommend Printed Name: Organization: Address: Phone:

6 APPLICANT REFRENCE STATEMENT TO THE APPLICANT Please print your name: (Last) (First) (Middle) The Family Educational Rights and Privacy Act and its amendments guarantee students access to their educational records. Students may, however, waive their right of access to references. The choice of the applicant regarding this reference is indicated below. Please circle your response: I do / I do not waive my right to inspect the contents of the following reference. Please request reference statements from three persons who have recent knowledge about your qualifications. On the first page of each reference form, fill in your name and give to the references. Ask each of them to send it back to you in a sealed envelope after they have signed across the seal. Send these three unopened references together, with the other application materials, to the. Opened reference letters cannot be accepted. References must not come from a relative. References should be obtained from a current or previous employer, faculty or professional peer. TO THE REFERENCE The above named person is applying for admission to the DNP program at Washburn University, and has given your name as a reference. We seek students who demonstrate potential for graduate academic work as well as commitment to the profession of nursing. Students should demonstrate the following characteristics: critical thinking and decision making abilities excellent verbal and written communication skills ability to analyze, synthesize and utilize knowledge Please provide us a candid assessment of this applicant regarding her/his suitability for our program. You are encouraged to attach a separate letter with this form. When you have completed this reference, please return it to the applicant in a sealed envelope with your signature across the seal. He/she will include this in the application packet.

7 1. How long and in what capacity have you known the applicant? Nature of relationship (employer, co-worker, faculty): 2. What is your estimate of the applicant s potential to be a successful candidate in this DNP Program? 3. Please indicate the applicant s ability and professional competence in comparison to other individuals whom you have known at similar states in their career. EXCELLENT VERY GOOD BELOW N/A Intellectual Capacity Self-reliance, motivation Ability to deal with stress Emotional stability and maturity Critical thinking skills Writing skills Verbal skills Growth potential Skills in relating to others Cultural sensitivity Organizational ability Creativity 5. Other Comments: (Academic abilities, commitment of nursing, values and ethics, emotional stability and maturity, readiness to enter the DNP program.) 4. I would: Highly Recommend Recommend Recommend with reservation Not recommend Printed Name: Organization: Address: Phone:

8 APPLICANT REFRENCE STATEMENT TO THE APPLICANT Please print your name: (Last) (First) (Middle) The Family Educational Rights and Privacy Act and its amendments guarantee students access to their educational records. Students may, however, waive their right of access to references. The choice of the applicant regarding this reference is indicated below. Please circle your response: I do / I do not waive my right to inspect the contents of the following reference. Please request reference statements from three persons who have recent knowledge about your qualifications. On the first page of each reference form, fill in your name and give to the references. Ask each of them to send it back to you in a sealed envelope after they have signed across the seal. Send these three unopened references together, with the other application materials, to the. Opened reference letters cannot be accepted. References must not come from a relative. References should be obtained from a current or previous employer, faculty or professional peer. TO THE REFERENCE The above named person is applying for admission to the DNP program at Washburn University, and has given your name as a reference. We seek students who demonstrate potential for graduate academic work as well as commitment to the profession of nursing. Students should demonstrate the following characteristics: critical thinking and decision making abilities excellent verbal and written communication skills ability to analyze, synthesize and utilize knowledge Please provide us a candid assessment of this applicant regarding her/his suitability for our program. You are encouraged to attach a separate letter with this form. When you have completed this reference, please return it to the applicant in a sealed envelope with your signature across the seal. He/she will include this in the application packet.

9 1. How long and in what capacity have you known the applicant? Nature of relationship (employer, co-worker, faculty): 2. What is your estimate of the applicant s potential to be a successful candidate in this DNP Program? 3. Please indicate the applicant s ability and professional competence in comparison to other individuals whom you have known at similar states in their career. EXCELLENT VERY GOOD BELOW N/A Intellectual Capacity Self-reliance, motivation Ability to deal with stress Emotional stability and maturity Critical thinking skills Writing skills Verbal skills Growth potential Skills in relating to others Cultural sensitivity Organizational ability Creativity 5. Other Comments: (Academic abilities, commitment of nursing, values and ethics, emotional stability and maturity, readiness to enter the DNP program.) 4. I would: Highly Recommend Recommend Recommend with reservation Not recommend Printed Name: Organization: Address: Phone:

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