Application for Admission

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1 Eastern Oklahoma State College - Nursing Division Application for Admission Generic Nursing Program (4 semesters): Application period is January 1st through February 15th Transition with LPN or EMTP Licensure (3 semesters): Application period is September 1st through October 1st You are urged to give careful consideration to each question on this form. It is your advantage to fill out this form completely and return it promptly. Options for submittance of COMPLETE application: 1. Personally deliver the application to the nursing department in Gunning Hall, Room Mail to 1301 West Main, Wilburton, OK with Attention: Nursing Department. 3. Fax to (please be aware that some transcripts are hard to read via fax). If sent by mail or faxed, you may confirm delivery by calling the nursing department at Date of Application: Desired Entrance Date (fill in year and circle one): August January (transition) Please check the appropriate box: New Applicant Transfer from Nursing Program Readmission Name (print or type): (first) (middle) (last) (maiden/other name used) Address: (street or PO box) (city) (state) (zip) Primary Phone: Alternate Phone: Date of Birth: Age: Gender: Male Female *U.S. Citizen: Yes No *Ethnic Group: Native American African American Hispanic Caucasian Other *I am a person with a disability: Yes No *I am a veteran: Yes No * For reporting purposes only

2 1. Provide information concerning high school graduated from or GED equivalency AND include a copy of diploma or equivalency with application. (name and location of school) (year degree/certificate received) 2. Provide information concerning any college, university, or any other school attended. Include a copy of EACH transcript (including Eastern) with your application. LPN and EMT must include vocational transcript. Name and Location of School Dates of Attendance (Month/Year) Degree Received *Please attach a page for additional college information 3. Are you currently a state certified CNA, LPN, or EMT? Yes No (In accordance with the Oklahoma Board of Nursing guideline, Oklahoma LPN license should not be copied. Please verify current licensure by printing from 4. If you have ever attended any RN school, provide the following information: (name of school) (city and state) (month/year of entrance) (reason for leaving) *If transferring from another school of nursing, a reference letter from a dean or nursing faculty is required. 5. If you feel that there is additional information needed to further explain any item on your nursing application, please attach your explanation as a separate page with this application. 6. A national background check is required with this application. Please see separate instruction sheet included in the packet. This will be at the cost of the applicant and must be done within 90 days prior of application to the nursing program. This is confidential and only you can access this background check from the website. A copy must be included when the application is received. Please be aware the background results may take a week or more to process.

3 In compliance with Oklahoma State Board of Nursing Registration and Nursing Education, the following information is necessary in order to take the National Council Licensure Examination for licensure as an RN. 7. Have you taken the examination for registered nurse licensure in any other state? Yes No 8. Have you been licensed in any state as an LPN/LVN or EMT-P? Yes No If yes, which state: (please include verification from each state) Is your licensure currently unrestricted? Yes No Indicate name on license (if different than application): 9. Have you ever had any action taken by a State Board of Nursing (LPN) or licensing body (EMT-P) regarding licensure? Yes No 10. Have you ever been arrested, convicted, or charged of a crime? Yes No *Omission of information or falsification can result in non-acceptance. Please include all such incidents no matter how minor the infraction, whether guilty or not. Please see the Oklahoma Board of Nursing rules below in reference to felonies Have you ever been judicially declared incompetent? Yes No 12. Do you have any physical limitations/disabilities that may interfere with your clinical performance? Yes No If you answer YES to any of the above questions, you must submit details on a separate page or your application will not be reviewed. According to the Oklahoma Board of Nursing, An individual with a felony conviction or who had sentencing terms imposed by the court related to a deferred sentence for a felony offense cannot apply for licensure for at least five years after completion of all sentencing terms, including probation and suspended sentences, unless a presidential or gubernatorial pardon is reviewed [59 O.S & 567.6]. I understand that I must have a minimum current cumulative GPA of 2.5 for application to be considered. I understand that I must have an ACT composite score equal to or greater than 19 or EOSC residual ACT scaled score of greater than or equal to 19 to be considered. I have met with a nursing advisor prior to submitting my application. (The nursing advisor list can be found at or by calling ) I hereby certify that I have answered all questions completely and accurately to the best of my knowledge. I understand that misrepresentation may result in non-acceptance or dismissal from this nursing program. (signature of applicant) (date)

4 Eastern Oklahoma State College - Nursing Division Physical Qualifications It is important to note that in order to successfully progress through the nursing curriculum and function as a practicing nurse upon graduation, an individual must be able to perform certain physical activities that include vocal, visual, auditory, and dexterity requirements. Therefore, in order to be considered for admission or to be retained in the program after admission, all applicants will: 1. Have physical strength to lift a minimum of 25 pounds. 2. Have visual acuity to read small print and medicine labels. 3. Have sufficient auditory perception to receive verbal communication from clients and members of the health team and to assess health needs of people through the use of monitoring devices such as stethoscopes, IV infusion pumps, cardiac monitors, fire alarms, etc. 4. Communicate in clear English speech patterns verbal and written. 5. Demonstrate coordinate range of motion of all four extremities without assistive devices. 6. Must be able to demonstrate appropriate and rational behavior while under mental and emotional stress. The individual will need to notify the Nursing Director in writing if such a disability exists or occurs during the admission process. Professional documentation will be requested regarding the individual s ability to perform nursing tasks. I certify that I meet the above requirements. (This form must be returned with your application.) (signature of applicant)

5 Eastern Oklahoma State College - Nursing Division Campus Selection Form Please check ONE of the following boxes and return with your application I am applying for the nursing program at SOSU-MCC in Idabel, OK I am applying for the nursing program at the EOSC Campus in Wilburton, OK Wilburton applicants: Please check below if you would prefer to attend the McAlester campus during your 2nd year of nursing instead of the Wilburton campus. Please note: Although every effort will be made to accommodate student campus selection requests, there is no guarantee of this occurrence. Accommodations will be made depending upon campus availability and class size.

6 Eastern Oklahoma State College - Nursing Division Application Checklist Met with Nursing Advisor (please specify) Bullock (Wilburton GUN 106) Kuykendall (Wilburton GUN 201) Durant (Wilburton GUN 107) Spiegel (McAlester 229) Fields (Idabel N 103) Strickland (Idabel N 104) Nursing Application Physical Qualifications Agreement Transcripts from each college (including EOSC if attended) Current Cumulative GPA = or > 2.5 ACT Scores English Reading Math Science Composite High School Transcript or GED Certificate with scores Science Grades (if completed) Anatomy Micro Phys. Nutrition Campus Selection Wilburton Idabel McAlester (soph. only) Background Check Letter concerning YES to #6-11 (if applicable) Copy or verification of CNA, LPN or EMT (If applicable) Exit interview and plan of action (If applicable) LPN or EMT-P Transition Direct Articulation OR Nursing Exams License: Expiration Date: 800 Work Hours (must have before entering sophomore year)

7 Criminal Background Check Instructions On January 1, 2004, the Joint Commission on Accreditation of Healthcare organizations (JACAHO) instituted new regulations that must be followed in order for hospitals, home health agencies, clinics, etc., to gain or maintain accreditation status. One of these new regulations requires all persons who are involved in-patient care activities, i.e., employees, volunteers and students must have criminal background checks as well as other healthcare related checks. Here is what you need to do: 1. Go to the secure link below: 2. Enter the Username and Password below: Username: easternok5231 Password: background 3. Create a personal profile by completing the required fields A. If your has been used in a previously created profile you will need to log in via the Returning Student Log-In section, select the New Screening Profile link on the next page. B. If you have forgotten your password you can click on the password (forget?) link and answer the security question you chose when you first creating your personal profile. 4. Complete each section of the screening profile A. Choose a payment option: i. Credit Card (Visa or MasterCard) $35.50 plus $1.00 administrative fee ii. PayPal $35.50 plus $2.00 administrative fee iii. Money Order or Cashier s Check $35.50 B. Review the screening profile to ensure all sections are complete and click Next C. Read the Notice and Disclosure and check the confirmation box D. Read the Summary of Rights under the Fair Credit Reporting Act and check the confirmation box. E. Fill out all form fields in the Certification and Release and enter your signature in the electronic signature box. i. You must have Java installed to complete the electronic signature F. Confirm the information is correct on the next page and select Submit Results can be accessed via the Retrieve Existing Report link on Instructions on how to access your completed report via your profile page will also be sent via once your profile has been created. If you have any questions please feel free to contact Maye Durant at or edu. You may also contact Validity Screening Solutions with technical questions at , toll-free at or via at

8 Criminal Background Check Results Upon the completion of your background check, results can be obtained the following ways: Go to and click on the Retrieve Existing Report link. Click on I am a student requesting a copy of my most recent background check report and click Continue. Enter your last name, social security number, date of birth and your address and then click on Request Report. From here, your report will be sent to the address you provided. An will be sent to the address that was provided in the background check request stating the report is now completed. You will also see the following information in the If you would like to view or print your background check report, screening profile, disclosure, Summary of Rights or any other documents associated with your screening profile, you can return to the following link any time, login with your institution-provided credentials, and then login as a returning student with your account credentials to access your profile: Go to and first log in with the following information: Institution-provided credentials: Username: easternok5231 Password: background Go to the top right-hand corner and enter your personal log-in information in the Returning Student Log In fields. Remember that your username is your full address, followed by the password you created. Once logged in, you will see all of the documents that you can now access.

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