APPLICATION FOR ADMISSION MSN PROGRAM BELLIN COLLEGE 3201 Eaton Road Green Bay, WI 54311
1-920-433-6628 or toll free 1-800-236-8707 x6628 For questions, email:
[email protected]
Website: www.bellincollege.edu OFFICE USE:
NONDISCRIMINATORY POLICY STATEMENT It is the policy of Bellin College to be nondiscriminatory because of color, race, national origin, religion, age, sex, marital status or handicap in the admission of students.
TRACK OPTION: DATE APPLICATION RECEIVED:
__________________
You are urged to give careful consideration to each question on this form. It is to your advantage to fill this out completely. Return the application promptly to the Admission’s Office of Bellin College WITH $50 NONREFUNDABLE APPLICATION FEE. PRINT OR TYPE ALL INFORMATION BELOW: Last Name:
First Name:
Date of Birth
Middle Name:
Email Address:
(Example: 01/01/1999):
Social Security Number:
_____
- ___ - _____
Previous Last Name(s):
Nick Name: Gender:
Male
Female
RN Licensure: (please attach copy)
Ethnic Heritage: Check one below. The following student data does not affect your admission status and is requested only to aid in the completion of federal, state, and college reports.
State(s)
Are you a Veteran? Yes No If yes, select one:
1. Ethnicity: Are you of Hispanic or Latino/a origin? Yes No
Chapter 30 Chapter 31 Chapter 33 Chapter 1606 Chapter 1607 Unknown
2. Race: Choose one or more from the list below: American Indian/Alaska Native Specify tribal affiliation __________________ Asian Laotian Cambodian Vietnamese Other _______________
License Number
Expiration date
Are you a U.S. Citizen?
Yes
No
(If ‘No’, you must complete the International/Non-U.S. Citizen application.) Did either parent attend or complete college? Yes No Have you applied to Bellin College in the past? Yes No
Are you a dependent of a veteran?
Yes
No
Black/African American Native Hawaiian/other Pacific Islander White PROGRAM TRACK – See catalog for description. Please indicate which program track for which you are applying : Nurse Educator
Family Nurse Practitioner
ADDRESS INFORMATION – Provide the address where you prefer to receive college mail: Primary Address: Telephone
Number, Street and Apartment
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(Area Code) + Number
City
Cell Phone
State
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(Area Code) + Number
Zip Code
Work Phone
County of Residency
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-
(Area Code) + Number
Check if Permanent Address is same as above primary address. If not, provide below: Permanent Address: Telephone
Number, Street and Apartment
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-
(Area Code) + Number
City
Cell Phone
Bellin College MSN Application (Printable)
Rev. 4/2014
State
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(Area Code) + Number
Zip Code
Work Phone
County of Residency
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(Area Code) + Number
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EMERGENCY INFORMATION – Person to be notified in case of emergency: Name: Address: Telephone
Last Name Number and Street (if different than above)
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Relationship:
First Name
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(Area Code) + Number
City
Cell Phone
State
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(Area Code) + Number
Zip Code
Work Phone
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(Area Code) + Number
POST-SECONDARY EDUCATION – List all educational institutions attended following high school AND any current college courses. IMPORTANT: Official transcripts MUST be mailed from institution directly to Bellin College to be accepted. Transcript Dates (mm/yyyy) Name of Institution City and State Degree Requested From To (Self-Check)
REFERENCES: List two individuals who will be receiving the reference form. Two professional references (1 academic, if appropriate). It is the responsibility of the applicant to distribute their reference forms. 1.
Name:
Position or Title:
2.
Name:
Position or Title:
CRIMINAL HISTORY: Do you have a conviction record or pending charges (excluding minor traffic violations)?
Yes
No
If you checked yes to the previous question, please contact the Vice President of Student Services for further direction before applying to the College. Bellin College reserves the right to deny admission or to terminate enrollment of any student because of his or her criminal history. Prior to practicum placement, a criminal background check will be completed. This background check is completed to remain in compliance with the Wisconsin Caregiver Background Check and Investigation Legislation. If any of the information provided in this application changes during your enrollment at Bellin College you agree to supplement this application with additional information. It is understood and agreed that any misrepresentation, false statement or omissions by me in this application or during any interview conducted in connection with my application may result in denial of acceptance into Bellin College or termination of my status as a student of Bellin College without liability to the College.
____________________________________________________________________ Applicant’s Signature
Print, complete, and sign application. Mail with application fee to:
Bellin College MSN Application (Printable)
Rev. 4/2014
_____________________________ Date MSN Admissions BELLIN COLLEGE 3201 Eaton Road Green Bay, WI 54311
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