College of Nursing and Health Professions
Educating health professionals for the 21st century

Return this completed form along with official high school and university transcripts to the USI Respiratory Therapy Program, 8600 University Blvd. Evansville, IN 47712-3596. A seperate application and set of transcripts must be sent to the University of Southern Indiana, Office of Admissions.

The deadline is April 1 for entrance into the Fall class.
ADMISSION APPLICATION

1. Name_________________  __________________ _____ _________________
                    Last                                   First                    M.I.         Maiden

2. Home Address____________________________________________________

3. City____________________________State___________ Zip_______________

4. Home Telephone:(    )__________ Local Telephone:(    )_________________

5. Current Address______________________  ________________ ________  ____________
                                          Street                                   City                  State            Zip

6. E-Mail address_________________________

7. S.S.N._________-______-_________

8. Birth Date______/_______/______
                       Mo.     Day       Year

9. High School Attended____________________Year of Grad.___________

10. In case of emergency contact: ____________________________________

11. List all universities/colleges attended:
 
 Dates 
 Name of Institution
 City and State
 Credential Earned
(Diploma, Certificate, Degree)
 

      
 

      
 

      
 

      

11. Have you ever been on probation, suspended, dropped, or refused readmission to any university?
      Yes_____No____  If yes, please explain on a separate piece of paper.

12. Have you ever been convicted of a felony?
      Yes_____No____If yes, please explain on a separate piece of paper.

13. Indicate other Respiratory Therapy Programs where you have made application.
 
  ______________________________________________________________________________
 
  ______________________________________________________________________________
 
15. Employment History: (List present or most recent employment first.)
 
 Dates Title of Position  Employer  City and State 
 

      
 

      


     

15. I hereby give my permission to the Admissions Committee to inspect my application and academic records.

Date ____________ Signature__________________________________

Please return along with this application, official transcripts, and a letter explaining why you chose Respiratory Therapy as a career to:

UNIVERSITY OF SOUTHERN INDIANA
RESPIRATORY THERAPY PROGRAM
8600 UNIVERSITY BLVD.
EVANSVILLE, IN 47712-3596

The deadline is April 1 for entrance into the Fall class.
Any questions call (812) 464-1702 `