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                    California State University, Bakersfield

                                                                Department of Nursing

                                   Application to the Fall Quarter 2007

                                                Generic BSN Program

                                                                 Or

                                  Winter 2008 Accelerated Progams if offered                                                    

Before sending, please make a copy of this application for your records.  This application can not be emailed to CSUB Department of Nursing. Please mail or hand carry the application to:

CSUB Department of Nursing

29 RNC

9001 Stockdale Hwy

Bakersfield, CA 93311

** Please print or type            

SSN:_______________________  CSUB Campus ID:______________________

Name:__________________________________________________________________________________

                (Last)                                      (First)                                           (Middle)                    (Alias/Maiden)

Address:_________________________________________________________________________________

                                (Number & Street)                                                (City)                      (State)                     (Zip)

Mailing Address if Different:

________________________________________________________________________________________

                                (Number & Street)                                                (City)                      (State)                       (Zip)

Home Phone: (     ) _____________________       Cell Phone: (     )__________________________________

Email Address:____________________________________________________________________________

(1.) CSUB Enrollment

Check your status at the time of application (check all that apply)

¨  A student already enrolled at CSU Bakersfield with units completed on this campus.

¨  Newly enrolled student at CSU Bakersfield beginning:

¨      Winter 2007

¨      Spring 2007

¨      Fall 2007

                  Approximate date you applied to CSUB:_______________________

¨  A post-baccalaureate student   Major_____________Date of Degree_______

CSU Bakersfield Application to the Generic BSN Program

(2.) Colleges/Universities Attended

List in chronological order all colleges and universities you have attended, beginning with the school where you are currently enrolled. Give locations of each institution, the dates of your attendance and, if appropriate, the date of your graduation.

(3.) Residency

3a. Country of Citizenship:_________________________________________

(If you are not a citizen of the United States you must attach a photocopy of both sides of your Alien Registration Card and/or INS documentation.  Students under 19 years old must attach their parent’s INS documentation).

3b. Are you a legal California resident?                           _______Yes                         ________ No

3c. Permanent Resident of _________________County in the State of__________

(4.) Demographic Information –This section is optional and not used in selecting students for the program

4a. Date of Birth:______________________________

                                           (Month/Day/Year)

4b. Birthplace:_________________________________________________________

                                                                  (City/State/Country)

4c. Ethnic Background:

4d.           Gender   :                                               ___________Male                             ___________Female

(5.) Proficiency Level in Target Language

“All applicants whose native language is not English and who have not attended schools at the secondary level or above for at least three years full time where English is the principle language of instruction must present a score of 550 or above on the Test of English as a Foreign language (TOEFL)”.  The computer based TOEFL score is 213 or better (CSUB 2005-2007 Catalog, p. 25).  In addition, the Department of Nursing requires that applicants whose native language is not English take the Test of Spoken English (TSE) and achieve a minimum score of 50 or better.

5a.           TOEFL score:_____________         5b.           TSE score:________________

(6.) Military Service

Active Military_____ Yes _____No       Military Veteran_____ Yes _____No      Discharge Date:__________

                                                                                                                                                                           (Month/Year)   

(7.) Disadvantaged Background

7a. Educationally or Environmentally Disadvantaged Definition: “An individual from a disadvantaged background is defined as someone who comes from an environment that has inhibited the individual from obtaining the knowledge, skill and abilities required to enroll in and graduate from a school.  Some of these environmental background factors could include, migrant family, rural community, receiving welfare, large family, parents divorced, first to attend college, English as a second language, cultural inculcation, ie., residence on a reservation, migrant camp” (HHS).  If you consider yourself disadvantaged, please write a brief statement in the space below as to why you are disadvantaged.  If needed, attach an additional sheet of paper to the back of this application.

CSU Bakersfield Application to the Generic BSN Program

7b.Economically Disadvantaged Definition: “…comes from a family with an annual income below a level which is based on low-income thresholds according to family size published by the US Bureau of the Census, adjusted annually for changes in the Consumer Price Index, and adjusted by the Secretary of Health and Human Services (HHS) for adaptation to this program.”

To determine if a student comes from an economically disadvantaged background, a school must use the student’s parental income (regardless of independent/dependent or marital status). If your parents’ income is below that listed for the size of your family, you may be considered economically disadvantaged.

      Size of Parent’s family                                                   Income Level

1                                                                                             $19,140

2                                                                                             $25,660

3                                                                                             $32,180

4                                                                                             $38,700

5                                                                                             $45,220

6                                                              $51,740

7                                                              $58,260

8 or more                                                $64,780

Can provide evidence of being economically disadvantaged  _____Yes  _____No  If yes, attach a copy of the top two pages of your parent’s last year’s tax returns to the back of this application.

(8.) Health Care Work Experience

Have you had any experience working in health care?  _____Yes  _____No  

If yes, please complete the following section.

(9.) Community Service/Volunteer Experience

Have you performed community service or volunteer work?  _____Yes  _____No  

If yes, please complete the following section.

(10.) Assessment Technologies Institute (ATI) Test of Essential Academic Skills (TEAS)- CSUB does not require that the TEAS test be taken prior to or during the application process. If not already taken, upon entry into the nursing program, all students are expected to complete the Assessment Technologies Institute (ATI) Test of Essential Academic Skills (TEAS).  If not completed on or before entry, the student will not be eligible to continue in the nursing program cycle.

Have you taken the TEAS? ______Yes _____No     If yes, please have ATI forward a copy of your test results to Kathy Lewis at klewis3@csub.edu.

CSU Bakersfield Application to the Generic BSN Program

(11.) Nursing Prerequisite and Cognate Classes

Prior to applying to CSUB’s nursing program, applicants must have completed at least 5 of the 9 prerequisites by January 15, 2007.  No more than two prerequisite courses may be repeated once.  A minimum GPA of 2.8 in the nine prerequisites is required for application to this program.  In addition, a minimum GPA of 2.8 is required in the science and math classes.  Please complete the form that follows.  DO NOT wait until all prerequisite courses have been completed.  Prerequisites must be completed and documentation of completion received by CSUB Department of Nursing no later than June 15, 2007.  No summer work will be accepted. No prerequisite box may be left blank. This is required information, even if you have already provided transcripts to the Admissions office or CSUB Department of Nursing. For students applying to our traditional three year nursing program, cognate courses may be taken during the nursing program.  If you have completed these courses please indicate that below. For students applying to any accelerated nursing program, (if offered) all thirteen courses must be completed by June 15, 2007. Include planned repeats and indicate in the grade box “IP” for work in progress during Winter/Spring 2007.               

* 5 or more-quarter units or 3 or more-semester units are required in Chemistry. May be an inorganic, organic or combination inorganic/organic chemistry course.

CSU Bakersfield Application to the Generic BSN Program

(12.) Background Information

Have you ever been convicted of a felony? _____Yes  _____No

If considered for acceptance to CSUB’s nursing program, you will be expected to submit to and pay for a criminal background check.  Final acceptance will be based on the outcome of the background check.

(13.) Confirmation of Understanding

14a. Date (today's date) of this "Intent to Major" form for Fall 2007: _____________

          I, _________________________________ understand that I may be tested during

                              (signature required)

        the first week of school to assess skills essential to nursing.  The test results will be

        used for advising and counseling purposes.  Based on test results, I may be required

        to take supplemental courses.

        I understand that it is my responsibility to complete the application and be granted  

        admission to California State University, Bakersfield and to submit all required

        materials to the Department of Nursing by the deadlines I have been given.  I verify

        that I have read and understand the information in this application packet.  I further

        verify that all information I have provided in this application is accurate, true, and

        complete.  I understand that any discrepancy can disqualify me from current and

        future consideration for admission to the Nursing Program.

                Signature: _________________________________________

Printed Name: ______________________________________

Date: _____________________________________________

14b.  I, _____________________________________________ understand that the RN

                                        (signature required)

         licensing exam (NCLEX) cannot be taken until I graduate from the program.

If applicable, please enclose these items with your application

¨  Official transcripts for all colleges and universities attended. (CSUB students do not need to send in a CSUB transcript)

¨  TOEFL results

¨  TSE results – If you have taken TEAS, you need to have ATI email copies to klewis3@csub.edu

¨  Military service or Military discharge documents

¨  Evidence of educationally or environmentally disadvantaged status – brief statement as to why you consider yourself educationally or environmentally disadvantaged

¨  Evidence of economically disadvantaged status – top 2 pages of your parents last year’s tax return statement

¨  Health care Experience Documentation- letter from volunteer organization or employer