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Georgia Baptist College of Nursing
of Mercer University

Application for Admission Doctor of Nursing Practice Program

Directions:

Completion of the online application will be easier if you have the following information readily available.
* denotes fields that are necessary to complete the application.

Academic Background (dates of attendance, degree(s) awarded, GPA's)
RN licensure (Number(s))
Advanced Practice Certification Number
Information regarding any disciplinary actions
Standardized Tests (scores if available)
Name, address (postal and email) of your professional references.

Application:
* Program:

Personal Information
* First Name:
* Middle Initial:
* Last Name:
Former Last Name:
* Street Address:
* City:
* State
* Zip/Postal Code:
	Please provide a 9 digit zip code.
Province:
* County:
* Country:
* Birth Date: (mm/dd/yyyy)
* Birth Place: (City and State)
* Social Security Number: Do not use dashes(-)
Home Phone:
Cell Phone:
* Primary e-mail:
Gender:	Female Male
Marital Status:	Married Single
Religious Preference / Denomination:

Ethnicity: Select one:	Hispanic/Latino origin Not of Hispanic origin
Race: Select one or more:	American Indian or Alaska Native Asian Black or African American Native Hawaiian or other Pacific Islander White
* Citizenship:	Are you a U.S. Citizen? Yes No
	If not, what is your residency status?
	* Is English your native language? Yes No
	If not, please list native language:
	What is your country of citizenship?
	Are you in the U.S. under a visa; if yes, what type?
*Emergency Contact:	Name:
	Relationship:
	Phone:

* Academic Background
* College/University Attended:	* City/State:	* Entry and Departure Dates:	* Degree/Major:	* GPA:

One official transcript must be sent directly to Georgia Baptist College of Nursing of Mercer University from each school previously attended. International Students must have a third party translation of their transcripts.

Transcript Credentialing Service for Non - US Degree
Have you requested that your international transcripts be evaluated by one or more of the following services?
Education Credential Evaluators (ECE) (www.ece.org)	Yes No
Joseph Silny & Associates (www.silny.com)	Yes No
World Education Services (WES) (www.wes.org)	Yes No
Please note that the Commission on Graduates of Foreign Nursing Schools (CGFNS) is not approved for the academic evaluation of international transcripts.
The College of Nursing Georgia Baptist College of Nursing of Mercer University does not require either a background check or drug screening for admission. Failure to be honest in the completion of the application question (below) regarding prior conviction may result in an honor code violation and could result in dismissal from the program.
Clinical Agencies As a doctoral student, you may be required to provide a criminal background report and/or drug screening, at your own expense, if required by the clinical agency to which you are assigned, with results reported directly to the clinical agency, not Mercer University faculty or staff. If the clinical agency finds the results of the drug screening or criminal background check to be unacceptable, Georgia Baptist College of Nursing may not be able to provide further educational experiences, which could impede the student´s progression and completion of the nursing degree.
* Criminal Background Information
* 1) Have you ever been placed on probation, dismissed, or suspended from any college or university for reasons pertaining to academic integrity?
Yes No
If yes, send a Personal Statement that includes all facts that you believe bear on the significance of this circumstance to nursingadmissions@mercer.edu .
* 2) Have you ever been convicted of, or pled guilty or no contest to any felony or misdemeanor (excluding minor traffic violations)?
Yes No
If yes, please provide further information on a confidential basis by submitting an electronic response to nursingadmissions@mercer.edu.


* RN Licensure
States in which you are currently licensed as a registered nurse:
* State:	* Current License Number:	* Expiration Date (MM/DD/YYYY):



Countries (other than the United States) in which you are currently licensed as a registered nurse:
Country:	Current License Number:	Expiration Date (MM/DD/YYYY):


Certification Information
* Are you certified as an advanced practice nurse? Yes No
If Yes, indicate your area of certification:
Certifying Institution:
Certificate Number:

* Previous Disciplinary Information
Has any licensing board or agency in Georgia or any other state ever:
* (a) denied your application, for licensure, renewal or reinstatement? Yes No
* (b) revoked, suspended, restricted or progated your license? Yes No
* (c) requested or accepted surrender of your license? Yes No
* (d) reprimanded, fined or disciplined you? Yes No
If "Yes", have you included a certified copy of that board or agency´s action against your license with Relevant supporting documents in a sealed envelope from the board or agency with your application? Yes No
Have you included a personal, detailed notarized letter explaining each incident? Yes No
Provide the name of the agency or board in the space provided.

* Standardized Tests
* Have you taken the GRE? Yes No
GRE Test Scores
* Date (MM/DD/YYYY)	* Verbal	* Quantitative	* Writing




Have you requested official scores be sent to Georgia Baptist College of Nursing of Mercer University? Yes No
(Institutional reporting code R5025, Major: 0610)

Have you taken the TOEFL? (International students only) Yes No
Date (MM/DD/YYYY)	Reading	Listening	Writing	Speaking	Composite



Official TOEFL results must be submitted directly from the testing agency

* HONOR CREED AND PLEDGE Adherence to the Honor System is an obligation that all students are expected to meet when they are accepted into this academic community. In selecting Georgia Baptist College of Nursing of Mercer University, I adopt the Honor System by the following creed: As a member of the Georgia Baptist College of Nursing of Mercer University community, I am bound by honor to develop and uphold the highest standards of honesty and integrity, to strive for full intellectual and moral developments; and to accept my personal and academic responsibilities in the community. To attain these ideals, I embrace this Honor System as my way of life. In addition to living by the creed, I acknowledge that, as a student at the College of Nursing, I would be asked to pledge all quizzes, examinations, papers, projects, or lab work with the following pledge: On my honor, I pledge that I have neither given nor received help on this work, nor am I aware of violation on the part of others.
* Please Enter your initials in the provided box, acknowledging the Honor Creed and Pledge
Mercer University is committed to providing equal educational programs or activities, and equal employment opportunities to all qualified students, employees, and applicants without discrimination on the basis of race, color, national or ethnic origin, disability, veteran status, sex, sexual orientation, age, or religion, as a matter of University policy and as required by applicable state and federal laws, including Title IX. Inquiries concerning this policy may be directed to the Equal Opportunity/Affirmative Action Officer/Title IX Coordinator, Human Resources Office, 1400 Coleman Avenue, Macon, Georgia 31207, phone 478-301-2788 or contact baca_dh@mercer.edu, or in cases of Title IX concerns, these concerns may be referred to the Office of Civil Rights.
Please note the deadline to submit your application and all supporting documents: January 31, Priority and International Deadline February 28, Final deadline (based on space available)

Atlanta Emergency Hotline Number: (678) 547-6111
Macon Emergency Hotline Number: (478) 301-5335

Georgia Baptist College of Nursing of Mercer University

Application for Admission Doctor of Nursing Practice Program

Please note the deadline to submit your application and all supporting documents: January 31, Priority and International Deadline February 28, Final deadline (based on space available)

Georgia Baptist College of Nursing
of Mercer University

Please note the deadline to submit your application and all supporting documents:
January 31, Priority and International Deadline February 28, Final deadline (based on space available)