DALTON STATE COLLEGE DEPARTMENT OF NURSING RN-BSN APPLICATION

Read the RN BSN Application Instructions thoroughly before completing each item on the application.
Enclose all items requested in the application.
Beginning with the Fall 2013 class, there will be a $20 application fee charge. The application fee will be charged and deducted from your DSC Student Account. Students applying who are not current DSC students will be charged as soon as their acceptance to Dalton State is complete.

The completed online application must be received by April 5, 2013. You must also be accepted to Dalton State College to be considered for admission to the RN-BSN program. Dalton State College applications can be found on the Dalton State College website at www.daltonstate.edu. Returning students who have not attended Dalton State College for three or more consecutive semesters must fill out an Application for Readmission to be considered for admission.

A. Personal Data:

Name: (Last, First, Middle,and Maiden)
Street Address:
City, State and Zip:
Current Dalton State ID Number:
Telephone Number (Permanent):
Dalton State Email Address:

A. Educational Information:

List all colleges and universities you have attended (most recent first).
1 - School name
City/State/Zip
Dates Attended
Graduated	Yes No

2 - School name
City/State/Zip
Dates Attended

Graduated	Yes No
3 - School name
City/State/Zip
Dates Attended
Graduated	Yes No

4 - School name
City/State/Zip
Dates Attended
Graduated	Yes No

School from which you received your Associate Degree in Nursing (or Diploma)
Any official transcripts from other colleges should be mailed to: Enrollment Services Dalton State College 650 College Drive Dalton, GA 30720

C. Employment/Licensure Information:

Are you currently employed?	Yes No
If so, where are you employed?
How many years have you been employed there?
A Verification of Employment form must be submitted as part of the application process if applicant graduated from an ASN or Diploma program more than four years ago with documentation of 1000 hours of practice within the past 3 years. This form is located on the Department of Nursing web page and must be filled out by current and/or previous employers. The form should be mailed to the Department of Nursing office.

D. RN License Information:

RN License Number and State:
Is this a multistate license?	Yes No
License expiration:
*A copy of your license(s) or documentation of licensure application must be included with your packet.

A COMPLETED APPLICATION PACKET WILL INCLUDE:

Submission of Online Application Form Employment Verification Form (if applicable) Current, unencumbered nursing license or documentation of licensure application Current resume Current evidence of Basic Life Support (BLS) certification Unofficial college transcripts from all colleges attended Application packets should be submitted to Cheryl Nuckolls, Administrative Assistant, Department of Nursing, in Sequoya Hall, Room 153. Packets can also be mailed to Cheryl Nuckolls, Dalton State College, Department of Nursing - Sequoya Hall, 650 College Drive, Dalton, GA 30720.

*INCOMPLETE PACKETS WILL NOT BE CONSIDERED!!*

Please fill out the application form only once. You will receive a response from the Department of Nursing within one week of submission.