OLD DOMINION UNIVERSITY



SUPPLEMENTAL PRELICENSURE APPLICATION DEADLINE:FEBRUARY 15thDesired Date of Admission:FALL If applying through a military program, please circle:MECP STA-21 ROTCName:Other names in which records may appear:______UIN: (University Identification Number assigned when ODU application is Received in Office of Admissions)Mailing Address:County of Residence:Phone: Home Work/Cell _______ (Area Code) (Area Code)E-mail Address: _______Indicate status of online application to Old Dominion University as a degree-seeking student Accepted Submitted and official transcripts sent to the University’s Office of Admissions______ Completion date of the HESI A2 exam (Attach transcript)See testing center website for test dates for the HESI A2. Test dates are limited. Be sure to schedule early. The HESI transcript must be attached to your application otherwise it will not be considered and a zero will be scored. _____ Health care related certifications or experience (Attach documentation)._____ Transcripts AttachedAttach copies of transcripts for all educational institutions attended. Please do not mail separately. Unofficial transcripts are acceptable with this supplemental application. In chronological order, list all educational institutions attended since high school including ODU.InstitutionLocationDatesDiploma/DegreeReceived orHours CompletedGPAIndicate progress of the following prerequisite courses to meet admission requirements to the BSN program. (Grade of C or better required for transfer credit)Completion of prerequisite courses listed below. Indicate grade received, or “Planned” if planning to complete the course before the start of the program. NOTE: All must be completed before the fall semester begins. English 110C**Foreign Language I**English 211C**Foreign Language II**English 112L or 144L **Fine Arts “A”**Philosophy “P” **History “H” **Statistics 130MBiology 250Psychology 203SBiology 251Sociology 201S Biology 103 _______ Chemistry 105/106NElective credits (5)** 2nd degree students have automatically fulfilled these requirements.Signature of ApplicantDateReturn application with documentation of health care certifications and photocopies of transcripts attached to:Janice HawkinsOld Dominion University, School of Nursing4608 Hampton BoulevardHealth Sciences Building, Room 2134Norfolk, VA 23529APPLICATIONS RECEIVED AFTER FEBRUARY 15th WILL BE CONSIDERED ON A SPACE AVAILABLE BASIS. Health Care Experience Verification FormI have a license, certification, or registration to practice.Circle one: CNA, EMT, LPN, MLT, Navy HM, Army Medic, Other _____________________A copy of your license or certification must be attached to this form.I do not have a license but I was trained on the job or have volunteer experience at _________________________________ as a ________________________________I verify that I have worked ______________hours in this capacity.My job responsibilities included:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Supervisor’s Signature and Title: __________________________________________________Supervisors contact information (phone and email) ____________________________________ ................
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