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1 UAA School of Nursing (907) Phone 3211 Providence Drive (907) Fax BS in Nursing Science Registered Nurse Option Track APPLICATION FOR ADMISSION Application deadline: November 1 st Name Last First MI Previous Name(s) Student ID # Home Phone Work Phone UAA Address Cell Phone Other Address Mailing Address Current RN Licensure (State) (Number) (Expiration Date) You must have licensure as a registered professional nurse in the State of Alaska concurrent with the first nursing major course. Provide copy of Alaska RN license with this application. Post Secondary Education (College, University, Vo-Tech, etc.) List Nursing program first. Certification: You may petition to waive 3 credits of Nursing elective based on national certification. If you have national certification in a nursing specialty or intend to have certification before the end of the nursing program, please list: (Specialty) (Expiration date) Please indicate whether you will be attending PART TIME or FULL TIME What semester do you plan to begin the BS nursing major? Have you met with a Nursing Advisor to create a plan of Study? UAA is an EO/AA Educational Institution Please see other side of document

2 Work History: Begin with the most recent position. (A resume may be attached.) Date of Employment Employer Job Title/Responsibilities Recommendations: Please list the three individuals who will be submitting letters of recommendation. They should address professional nursing competence and prediction of success as a baccalaureate student. (i.e., an employer, co-worker, or former instructor) Letters from relatives will not be accepted. Forms are enclosed, and may be mailed separately to the School of Nursing. You are responsible for ensuring that they have been received. You must initial at the top of the recommendation form if you wish to waive your right to review the completed letter. Name Position Telephone Number BS applicants must submit an essay. Address the following questions in an essay not exceeding TWO pages in length using 12 point font, double spaced with 1 margins: What are your goals in the pursuit of this professional degree? What life experiences and/or personal qualities will foster your success? Signature Date Please return this application to: Coordinator of Student Affairs UAA School of Nursing 3211 Providence Drive, PSB 103

3 School of Nursing (907) Phone 3211 Providence Drive, HSB 101 (907) Fax Letter of Recommendation for BS in Nursing Science Registered Nurse Option Track By initialing here, I, the applicant, waive my right to read the completed recommendation form. Applicant Name: has applied for admission to the University of Alaska Anchorage, School of Nursing BS, Nursing Science RN Option. Your cooperation in completing and promptly returning this recommendation form will assist both the applicant and the School of Nursing in the admission process. The student has indicated above if he/she waives the right to review this recommendation form. If there are no initials above, you must assume that the applicant will be allowed to review the completed form. 1. How long and in what capacity have you known the applicant (i.e., friend, co-worker, employee, student)? 2. Please give your personal evaluation of the applicant in terms of the following: 4 = Excellent 3 = Good 2 = Average 1 = Poor N/A = Not applicable (insufficient knowledge) A. B. C. D. E. F. G. H. I. J. Willingness to work Work habits Perseverance Reliability Cooperation Leadership ability Creativity Personal integrity Communication skills Personal control in stressful situations Comments:

4 3. Please comment on the applicant's positive and negative attributes (strengths and weaknesses) that may contribute to success in the bachelor degree program: 4. Please indicate your overall endorsement of this applicant by checking one of the following: Highly recommend Recommend Uncertain Do not recommend Other Comments: Signature Date Printed Name Position/Title Organization Printed address address Telephone number This letter of recommendation will be placed in the student's file and upon request will be made available to the admission committee for review. This letter will not be reproduced. Please return this form directly to: Coordinator of Student Affairs UAA School of Nursing 3211 Providence Drive, HSB 101

5 UNIVERSITY OF ALASKA ANCHORAGE SCHOOL OF NURSING CONFIDENTIAL REQUIRED INFORMATION The following information is REQUIRED for Federal reporting purposes and to improve the ability of the School to compete successfully for grant funding. This information sheet will be separated from your application and used for statistical purposes only. The information provided will NOT BE USED in making admission decisions and will be kept confidential. However, applications lacking the required information will be considered incomplete and will not be considered for admission until the information is provided. PLEASE PRINT (OR TYPE) and CIRCLE ALL APPROPRIATE NUMBERS. Name Social Security # Last First M I Mailing Address Zip Code Street Address Zip Code Your current employment status: Source of income: 1. Unemployed 1. Employment 5. Unemployment insurance 2. Employed Part-Time 2. Student financial aid 6. Workman's compensation 3. Employed Full-Time 3. Parent/Guardian 7. Public Assistance 4. Self-Employed 4. Spouse/partner 8. Other: Highest education level (specify AREA OF STUDY for numbers 5-8): 1. Currently in high school 5. Vocational school 2. High school diploma 6. 2-yr degree 3. GED 7. 4-yr degree 4. Some college 8. Some graduate school 9. Graduate degree Current application: Semester and year of current nursing application: 1. AAS degree, Nursing (ANC, FBKS, Juneau, Kodiak, Sitka, Kenai, Bethel) 1. Fall 2. BS degree, Nursing Science 2. Spring 3. MS degree, Nursing Science 3. Summer Did either parent or guardian graduate from a 4-year college before your 18th birthday? Yes No Indicate your ANNUAL taxable family income $ Number of people supported by that income OPTIONAL INFORMATION Federal law prevents our requiring the information requested below. However, having this information enables the School to compete more effectively for Federal grant funding; therefore, we request that you provide the information VOLUNTARILY. The information you elect to provide will be kept confidential and WILL NOT BE USED in making admission decisions. Further, your application will be considered to be complete even if you elect to withhold the information requested below. Marital Status: Ethnic Background: 1. Single 1. American Indian (A) 6. Alaskan, Aleut (L) 11. Alaskan Indian, Athabascan (T) 2. Married 2. Black, non-hispanic (B) 7. Alaskan Eskimo, Inupiat (K) 12. Alaskan Indian, Other (I) 3. Separated 3. Hispanic (H) 8. Alaskan Eskimo, Yupik (Y) 13. Alaska Native, Other (N) 4. Widowed 4. Asian, Pacific Islander (P) 9. Alaskan Eskimo, Other (E) 14. Other (O) 5. Divorced 5. White, non-hispanic (W) 10. Alaskan Indian, Southeast (S) Date of Birth Gender: Female Male I understand that the information on this form will be used for statistical purposes only. All statements made are true to the best of my knowledge. SIGNATURE DATE

3211 Providence Drive, HSB 101 (907) 786-4559 Fax

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