Application for Admission

First Name *

Last Name *

Middle

Previous Name *

Address *

PO Box (Please provide street address also)

City *

State *

Zip *

Home Phone *

Work Phone

Mobile Phone

Email *

County *

Please list high school (G.E.D.) and all post-secondary schools attended *:

Institution

City, State

Dates Attended

Diploma/Degree

If transferring from another school, are you presently in good standing?

Yes No

Please list all work experience:

Employer

Position

Dates Employed

Please feel free to write any comments in support of your application:

Note: According to the Pennsylvania State Board of Nursing, an R.N. license will not be issued to persons who have been convicted of a felony prohibited by “The Controlled Substance, Drug, Device and Cosmetic Act” or a felony related to a controlled substance.

I certify that all of the information provided is correct to the best of my knowledge.

Once this form is submitted a confirmation page will appear which you must print and send, along with a $50.00 application fee (payable to The Washington Hospital), to:

The Washington Hospital
School of Nursing
155 Wilson Avenue
Washington, PA 15301