University of Southern Indiana

Application for RN-MSN / MSN / Post Master 8600 University Boulevard Evansville, IN 47712 812/465-1154 http://health.usi.edu Check the box to indicate your nursing program interest: RN-MSN (Check if you do NOT have a BSN) MSN Post Master Check the graduate specialty you intend to study: ACNP  CNS  Education  FNP  Management & Leadership Term applying for: **Please select one** Fall 2007 Spring 2008 Fall 2008 Spring 2009 Fall 2009 Preferred time frame to completion: **Please select one** Fulltime (2 years) Parttime (3 years/1 fall course & spring terms first year) Parttime (3 years/2 fall courses & spring terms first year) Parttime (4 years/1 course per term) Parttime (5 years/1 course per term - Nurse Mgmt/Leadership track only)       The University of Southern Indiana Undergraduate and Graduate Nursing Programs are accredited by the Commission on Collegiate Nursing Education (CCNE). Accreditation is an indication of public approbation, attesting to the quality of the educational program and the continued commitment of the sponsoring institution to support the program.       For further information about the accreditation of the program, please contact the Commission on Collegiate Nursing Education at (202) 887-6791 or write to the following address: One Dupont Circle, NW, Suite 530, Washington DC 20036-1120. This is NOT a secure form!        If you are not comfortable sending this information across the Internet please e-mail or call Kristina Walker, Advising and Recruitment Coordinator  kmwalker4@usi.edu 812.465.1150       First Name Last Name    Address City State/Province    Select State/Province  Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Overseas Europe (AE) Overseas Pacific (AP) ALBERTA BRITISH COLUMBIA MANITOBA NEW BRUNSWICK NEWFOUNDLAND NOVA SCOTIA NORTHWEST TERRITORY ONTARIO PRINCE EDWARD ISLAND QUEBEC SASKATCHEWAN YUKON TERRITORY Zip Code County    Phone Number E-mail    Please describe the following activities in detail. The size of text boxes will not limit your answers. I. Professional Portfolio A. Previous Education: List each institution, and whether or not credit was earned.      Begin the list with the most recent. College / University City / State / Country Dates Attended Degrees Received RN-MSN applicants must submit to the Office of Admissions, University of Southern Indiana, 8600 University Blvd., Evansville, IN 47712:    a) Official transcripts of high school or GED scores and all post high school education. It is also the responsibility of the student to have a seperate copy of the transcripts sent to the Graduate Nursing Office. b) The completed USI Undergraduate admission application . MSN and Post Master applicants must submit to the Office of Graduate Studies, University of Southern Indiana, 8600 University Blvd, Evansville, IN  47712:  a) Official transcripts from all colleges and/or universities.  b) The completed Office of Graduate Studies admission application NOTE: To be official, transcripts must be sent directly from the registrar of the institution to the appropriate above department. List workshops and continuing education for the last three years. Workshops / Continuing Education: Title Dates / Location CEU B. Membership in professional organizations.      List the Organization, dates of membership, offices held, and a description of activities      in which you participated. C. Research Participation:      List the title of the research project, the primary investigator, and describe your participation. D. Awards/Honors: List any awards or honors that you have received and describe the activities that led to the award or honor. E. Certificates: List all certifications with dates earned and expired. Certification Position Date F. Employment:     List the most recent first. Provide descriptions of each position held and reason for leaving. Current Employer     Employer Position Date Address (City, State, Zip) County Phone Number     Previous Employers Employer Position Date G. Have you ever been convicted of a felony? No  Yes H. Have you ever been convicted of a misdemeanor? No  Yes I. Have you ever been convicted of a sex offense against children? No Yes     (Requirement of Indiana Public Law 11-1994) J. Leadership and Community Activities: List community organizations, board memberships, offices held, and professional activities that serve the community. Include activities during the last three years. Organization Association Dates K. Personal Experiences: Describe personal experiences that you feel have contributed to your growth in the profession. II. References: List two professional references from nursing practice or nursing education. Click here to access and print out the Graduate Nursing Application Reference Form Ask each person to complete the Professional Reference Form. Provide them with a stamped addressed envelope addressed to the: University of Southern Indiana College of Nursing and Health Professions Graduate Nursing Program 8600 University Boulevard Evansville, IN 47702 Name / Title Address Phone III. Statement of Professional Goals: In a one-to-two page typewritten paper, describe your academic and professional goals and how graduate education will assist you in attaining these goals. Include a cover sheet with your name and Social Security Number. IV. Resume: Submit a copy of a current resume to the Graduate Nursing department. V.  License:  Submit a copy of your current nursing license(s) front and back to the Graduate Nursing department. VI. Emergency: Please list the person to be notified in the event of an emergency: Relationship: Telephone:   Please only press this button ONCE.