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					Mail to:                                                                                                                                Campus:  Bakersfield
           Bakersfield College
           Nursing Department
           1801 Panorama Drive
                                      Bakersfield College – Associate Degree Nursing Program
           Bakersfield, CA 93305                       Application Form
           Attn: Applications

      Admission to:                        Fall Semester       Spring Semester          Year:
      Nursing Semester:                    1st Semester         2nd Semester             3rd Semester                 4th Semester
                                                              Personal Information

      Full Name:
                     Last                                           First                                             M.I.              Previous Last
      Address:
                     Street Address                                                                                                     Apartment/Unit #


                     City                                                                            State              ZIP Code
      Day Phone:            (     )         -                          Alternate Phone:               (      )           -

      Student ID #:         @                               Birth Date:             /           /

      U.S. Citizen?         Yes       No          **Do you have a valid Social Security or Tax payer ID Number?                             Yes   No

      Have you ever applied to a Bakersfield College Nursing Program?                                Yes         No

      If Yes, Under what name?                                                     When?

      Have you ever enrolled in a Nursing Program?               Yes         No           Where?                                      When?

      Have you taken the TEAS?              Yes       No             Were you previously an Alternate?                       Yes       No

      I have completed all steps of the remediation plan and have attached proof of each required
      course.                                                                                                                               Yes   N/A
      Have you already attained a college degree?              No           AS     AA               BS       BA                    Major:

                If applicable, attach proof of college degree.

                                                                 Job Information
      Name of
      Employer:                                                                           Position:

                                                               College Education

                        College Name                                  City/State                     Dates Attended                    Degree Earned




       If you have completed equivalent course work at another college, you must request equivalency certification
            from the BC Admissions and Records Office and submit this equivalency in the form of an unofficial
       Bakersfield College transcript to the program during the application-filing period. Failure to have transcripts
                        evaluated will result in ineligibility to the Bakersfield College ADN Program.

            **The California Board of Registered Nursing requires possession of either a Social Security number or Tax payer ID number to apply for
                            licensure. Please provide a copy of your Tax payer ID Card if you do not have a Social Security number.


                                                    Please Complete Reverse Side
                                                                                                                                       Page 1 of 2
           10/2009
Demographic Information (optional)

Please complete the following survey.

Male              Female

Your age (please mark one of the following)

          < 24 years of age
          25-30 years if age
          31-40 years of age
          41-50 years of age
          51-60 years of age
          > 61 years of age

Racial background (please mark one of the following)

          American Indian or Alaskan Native
          Asian or Pacific Islander
          African-American
          Filipino
          Hispanic
          White, other than Hispanic
          Other/Unknown

ESL       _____ Yes      _____ No

This form, plus transcripts showing equivalent coursework, must be received before your application form
will be processed. The filing periods are March 1- March 31 for application to the fall semester and
September 1 – September 30 for the application to the spring semester.

It is the applicants responsibility to keep the Allied Health Office informed of any changes in address or
phone number.


                                             Acknowledgement
I certify that to the best of my knowledge all information provided on this document is complete and
accurate. I understand that any false or omitted information, intentional or otherwise, will result in
removal of consideration for the program.

Signature                                                             Date

                                    Release of Information (optional)
By signing below, I agree to allow the Bakersfield College Associate Degree Nursing Program to release
my name, telephone number and ranking to area hospitals for possible acceptance into the hospital
sponsored seats in the Bakersfield College ADN Program.

Signature                                                                 Date


                                                                                                 Page 2 of 2
10/2009

				
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