ADMISSION APPLICATION COMBINED BSN/MSN PROGRAM FOR FOREIGN-EDUCATED PHYSICIANS

Instructions: Please type or print all information
Semester Applying for:___________________ Name: _____________________________________________ Last First Middle/Maiden SS# ____/___/____ Panther ID# __________

Gender: Male

Female

Date of Birth ___/___/___

Country/State of Residence: _______________________________________________

Ethnic Origin: White Black Asian Hispanic American Indian or Alaskan Native

(Not of Hispanic Origin) (Not of Hispanic Origin)

Local Address: Street: City/State/Zip Code: Phone/Fax: Home ( E-mail Address: Permanent Address: Street: City/State/Zip Code Phone/Fax Home ( ) Work ( ) ) Work ( )

EMPLOYMENT INFORMATION
Place of Employment: Position: How long:

EDUCATION
High School Attended: College/Universities attended (List from most recent) City/State Graduation Date: _____/_____/_____ Dates Attended Degree

If any have attended any School of Nursing previously, please give the following information: Name of School Address Dates Attended

Reason(s) for withdrawing: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ Have you ever worked in another health care capacity (e.g.) C.N.A., LPN, EMT, Paramedic, etc.)? No Yes (explain)

Have you ever been charged with a violation of the law, which resulted in probation, community service, a jail sentence, or the revocation of your driver’s license (including traffic violations, which resulted in a fine of $200 or more)? No Yes If yes, you must provide a written explanation of the incident. Signature: __________________________ Date: _______________

Please attach a typewritten essay of 300-500 words describing yourself, your professional/life goals, and your reason for wanting to become a nurse. Return to the attention of Marnie Munoz: Florida International University College of Nursing and Health Sciences 3000 NE 151st St.; ACII-200 North Miami, FL 33181

Revised 02/25/2011