RN to BSN Program Application

General Info

* Please enter today's date:

* When do you wish to begin taking RN to BSN courses?

* Last Name:

* First Name:

Middle Initial:

Previous Last Names:

* Date of Birth:

* Place of Birth:

* What is your ethnicity?:

Hispanic or Latino

Not Hispanic or Latino

* Marital Status:

Single

Married

Divorced

Widowed

* Gender:

Male

Female

Mailing and Contact Info

* Home Address:

* City:

* State:

* Zip Code:

* Cell Phone:

* Email Address:

* Please Verify Your Email Address:

Employment InformationList your current and past employment for up to five years. This information is used for accreditation purposes. Please include supervisor name and contact information.

* Current Employer:

* Position:

* Supervisor Name:

* Supervisor Email Address:

* Supervisor Phone Number:

Past Employment Info:

Education Info

What school did you attend for your prelicensure nursing program?

What schools have you attended? Please include all schools attended and list any earned degrees.:

Which of the following best addresses your purpose in applying for the RN to BSN Program at Oklahoma Panhandle State University? (Choose all applicable responses).

I wish to advance my career as an RN in management or leadership positions.

I wish to maintain my current position and a BSN is now required.

I am seeking and/or have employment at a Magnet status hospital and a BSN is required.

I plan to further my nursing education with an advanced degree in nursing (i.e. MSN, APRN, CRNA, etc.).

I plan to further my education with an advanced degree (i.e. MBA, etc.).

Other (please describe).

Other Purpose in applying:

Licensure

Are you a licensed Registered Nurse?:

Yes

No

Not yet, but I am scheduled to take the NCLEX or will be eligible to take the NCLEX in the next 6 months

What state(s) are you licensed to practice in?

If licensed in a compact state please list declared home state only.

Please enter your license number.

If licensed in a compact state please list declared home state only.

* Have any of your licenses ever been suspended or revoked:

Yes

No

If yes, please explain:

Certifications

List any certifications you currently hold or have held in the past:

Submit Application

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