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RN-to-BSN-Application - RN to BSN Application for Admission...

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RN to BSN Application for Admission
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PERSONAL INFORMATION Last name First name Middle initial Maiden/other last name Preferred first name Address City State ZIP Code Home phone Cell phone Email address Social Security Number Birthday (mm/dd/yy) Birthplace (city/state) Gender: £ Male £ Female Religious preference: £ Church of Christ £ Community Church £ Baptist £ Methodist £ Lutheran £ Catholic £ Other Name of your church congregation Marital status: £ Single £ Married £ Separated £ Divorced Do you consider yourself to be of Hispanic/Latino/Spanish origin? £ Yes £ No In addition, please select one of the following racial categories to describe yourself: £ Asian/Pacific Islander £ Black (non-Hispanic) £ Hispanic multi-racial £ Native American £ White (non-Hispanic) Are you a U.S. citizen? £ Yes £ No If no, in which country were you born and of which country are you a citizen? Are you a veteran? £ Yes £ No If so, do you expect to receive VA benefits? £ Yes £ No Have you been convicted of a criminal offense other than minor traffic violations?
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