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1 Missouri State School of Anesthesia RN to DNAP Professional 400, 901 S. National Ave- Springfield, Mo Phone: : Fax: Please mail; Fax; or this application to the address listed above along with a $50.00 application fee made payable to Missouri State School of Anesthesia Full Name: Last First Middle Address: Phone: SSN: Nursing Lisc: _ Nursing Program Completion Date_ Bachelors Program _Completion Date_ Degree Conferred: (BS; BSN etc) Have you previously applied to this program? Please provide answers to the following questions: Have you ever been admitted to and then released from any other schools of anesthesia? If yes please explain the circumstances Have you ever had you license suspended or revoked? if yes please explain Please provide a full criminal history, excluding traffic offenses RN to DNAP

2 NOTE: Application with related material (To include Transcripts) Become the Property of the Missouri State School of Anesthesia and will not be returned to the Applicant. Please complete all of the items on the APPLICATION CHECKLIST! It is your responsibility to make sure all the items are received and complete. After receipt of all document, acceptable candidates will receive a letter inviting you for an on campus interview. The interview will consist of 2 interviews by 2 separate panels. A campus tour, time for questions, financial aid etc will be available. The admissions committee will then select the cohort, and a letter will be sent for a position in the cohort. Once the position is accepted, students will be required to pay a $500 place holding fee known as the Confirmation Deposit. The link to pay for this is found online. A program of study will be sent along with all documents for the required background check and drug screen.

3 Missouri State School of Anesthesia Agreement/Authorization/Release By applying for appointment to the Missouri State School of Anesthesia I hereby: Agree to appear for interviews in accordance with the application process; Acknowledge that I have received, or been given access to read, the Rules and Regulations for the Missouri State School of Anesthesia and confirm that I agree to abide by the same: Agree to abide by the policies and procedures of the Missouri State School of Anesthesia and the policies and procedures of Missouri State University and its related facilities; Authorize the Missouri State School of Anesthesia and designated representatives to consult with and obtain information from my prior associates, members of Nursing staffs to which I was/am a member, other hospitals, insurance carriers, health plans, HMOs, the National Practitioner Data Bank, the Missouri State Board of Nursing and other state licensing boards and others who may have information bearing on my professional competence, character, health statues, ethics, performance and ability to work cooperatively with others; Release from liability Missouri State University (including but not limited to the School of Anesthesia) and all its board members, officers, employees, volunteers, students, agents, and assigns for all actions, statements, and the like associated in anyway with evaluating my application and my credentials and qualifications; Release from liability all individuals and entities who provide information to Missouri State University concerning my application, credentials, qualifications, professional competence, ethics, character and other qualifications of staff appointment and clinical privileges; Acknowledge that I, as an applicant for the Masters in Nurse Anesthesia Program have the burden of producing adequate information for a proper evaluation of my professional, ethical and other matters. Agree to immediately notify the Missouri State School of Anesthesia of any disciplinary action affecting me (including, without limitation, reprimands or warnings or reduction, probation, modification, suspension or revocation of privileges) Imposed by any other health care provider and authorize all other health care providers to disclose information to the Missouri State School of Anesthesia or representatives relating to disciplinary action affecting me at such other health care providers; Acknowledge that all information submitted by me in this application is true, complete and correct to my best knowledge and belief and that any misstatements in or omissions from this application constitutes cause for denial of appointment or cause for summary dismissal from the Missouri State School of Anesthesia; Authorize the Missouri State School of Anesthesia to use photocopies of this release form as original signature. Date: Signature: _Name: (Please print or type)

4 RN to DNAP Application Checklist: These materials must be included in your application in order for it to be complete and to be processed for interview consideration. You will not be notified of missing items. It is the applicant s responsibility to make sure the application is complete!!! Application deadline is November 1st. Completed application to the Missouri State School of Anesthesia AND completed application to MSU Graduate College. _ Essay on why you are qualified for admission, Nursing history, goals. No more than words double spaced. Copy of your certifications (Nursing license, BLS, ACLS, and PALS.) GRE Scores a. Your official scores will get sent to MSU. (The graduate college school code is R6665). They are an official site for GRE scores. b. The School of Anesthesia is NOT an official site to send GRE scores. THEREFORE: It is the applicant s responsibility to get a copy of your scores along with your application to the School of Anesthesia before the deadline. Current Resume/Curriculum Vitae Non-refundable application fee--$50.00 (This must be a check made payable to the Missouri State School of Anesthesia.) Please note: MSU Graduate School and the School of Anesthesia have 2 separate application fees and 2 separate addresses!!!!! References: 3 letters of recommendation from non-relative medical professionals, including your current supervisor. These should be on official letterhead and signed by the professional. They may be sent directly to the School of Anesthesia or FAXed to _ Official transcripts from each institution must be sent to Missouri State School of Anesthesia AND the Missouri State University Graduate College. Transcripts MUST Include the 5 prerequisite courses: Microbiology, Anatomy, Physiology, Inorganic AND Organic Chemistry. Signed Agreement/Authorization form-----please print and sign Remember: It is your responsibility to make sure everything accompanies your application. You may follow up on your application with the School of Anesthesia at Missouri State by calling to make sure your application is complete. It is imperative that you send your documents to the correct address!!! ADDRESSES: Missouri State School of Anesthesia Missouri State University Graduate College Professional 400 ATTN: Graduate College 901 S. National Ave. 901 S. National Ave. Springfield, Mo Springfield, Mo

5 OFFICE USE ONLY: Application Date application received fee Agreement/Authorization/Release Form Application Education Degree College/University _Date of Graduation Required Coursework/Transcripts Microbiology Anatomy Physiology Inorganic Chemistry Organic Chemistry References Experience Total Years of Nursing Total Years of Critical Care Nursing PACU ICU CCU ER RR Neonatal ICU Neuro ICU Surgical ICU Other Certifications Current Nursing License BLS PALS ACLS GRE Date taken Scores: V Q AW_ Total GPA

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