School of Nursing: Undergraduate Application

RN APPLICATION - FALL ONLY
BACHELOR OF SCIENCE IN NURSING

This application is for Registered Nurses ONLY. If you do not have an RN license, do not fill out this application.

Name (use this order: LAST NAME, FIRST NAME, MIDDLE NAME or MAIDEN NAME):

Permanent Address:
    (no. and street)
    (city/state/zip)
Current Address (if different from above):
    (no. and street)
    (city/state/zip)
Permanent Telephone:
    (###)###-####
Current Telephone (if different from above):
    (###)###-####
Permanent County: Current County:

If you were registered in any college or university under any variation of your name as it appears on this application, please give such name here. (Affidavit will be requested where necessary):

At least part time employment is required. Please indicate below where you will be employed in the Fall semester.

Business Address:
(name or other relevant information)
                                (no. and street)
                                (city/state/zip)
Business Telephone:
                                (###)###-####
Date of Birth (##/##/####):
E-mail Address:
Citizenship: U.S.A. Other       Immigration Status:

Have you previously applied for admission to any undergraduate division/department/program at the State University of New York at Buffalo?
Yes No
If yes, when (month / 4-digit year):
In what area:

Have you ever attended any division of the State University of New York at Buffalo?
Yes No
If yes, give date of attendance: (mm/yyyy)
Student Number:

Colleges or Universities attended (Include Diploma & Certification Education):

1. Institution / Location:
    Dates (mm/yyyy): --
    Degree Received                      Area of
       with date (mm/yyyy)              Specialization

2. Institution / Location:
    Dates (mm/yyyy): --
    Degree Received                      Area of
       with date (mm/yyyy)              Specialization

3. Institution / Location:
    Dates (mm/yyyy): --
    Degree Received                      Area of
       with date (mm/yyyy)              Specialization

4. Institution / Location:
    Dates (mm/yyyy): --
    Degree Received                      Area of
       with date (mm/yyyy)              Specialization

Total college credits completed:

Current status in University at Buffalo:

Admitted Day Division (DUE)
On official leave of absence from UB

Not currently attending UB

Non-matriculated (have not applied to UB)
UB application filed on: (mm/dd/yyyy)

Academic advisor's name:

List courses for which you are currently registered and the college, if not UB. All 11 prerequisite courses must be completed by Fall. Please indicate all you are currently taking or where and when you will complete any remaining:

1.Courses: -- Where:

2.Courses: -- Where:

3.Courses: -- Where:

4.Courses: -- Where:

5.Courses: -- Where:
I am seeking admission to the School of Nursing Undergraduate Program for:

2008 (Fall only)

OPTIONAL: Caucasian African American Native American/Alaskan Indian Asian/Pacific Islander Hispanic

Female Male
Veteran? Yes No

NO PERSON, IN WHATEVER RELATIONSHIP WITH THE STATE UNIVERSITY OF NEW YORK AT BUFFALO, SHALL BE SUBJECT TO DISCRIMINATION ON THE BASIS OF AGE, CREED, COLOR, HANDICAP, SEXUAL ORIENTATION, NATIONAL ORIGIN, RACE, RELIGION, GENDER, MARITAL OR VETERAN STATUS.
Information requested on these subjects is for reporting by the School of Nursing to federal and other agencies collecting data to assure equal opportunity.

PETITION FOR SPECIAL CIRCUMSTANCES
If you believe there is any information which the admissions committee should know, such as any special circumstances which may have contributed to poor grades in the past or a reason why you have not met all of the criteria for admission at this time, please indicate in the text box below:

RN Licensure required to enroll.

Active RN License Registration:
License Number1:
License Number2:

Date licensed as an RN
OR
Date expecting to take exam:
RN license 1: Expiration Date:
RN license 2: Expiration Date:
Select one:
Associate Degree in Nursing Name of College
Diploma in Nursing Name of School
Date ADN or diploma received: (mm/dd/yyyy)

FOR DIPLOMA SCHOOL GRADUATES ONLY:
Graduates of hospital based diploma programs who do not hold the Associate Degree may be required to successfully complete Associate Degree level theory examinations in Nursing offered by Excelsior College (effective January 1, 2001 – formerly Regents College). Examinations must be completed prior to taking upper division nursing courses.
For information on these requirements, please contact the RN Program
Advisor, (716) 829-2155 or email
nurse-studentaffairs@buffalo.edu

DEADLINE FOR SUBMISSION OF THIS APPLICATION
RN TRACK PROGRAM June 1 for Fall (Recommended Deadline)