Bachelor of Nursing Program

Preferred Starting Term:

First Name

Last Name

Preferred Name

Birthdate

CONTACT INFORMATION

Mailing Address

Country

Street

City

Region

Postal Code

Phone Number

Cell Phone Number

Email Address

Occupation (Title)

Employer

Do you plan to utilize tuition reimbursement from your employer?

Yes

Do you wish to apply for Virginia in-state tuition?

Yes

Please complete the application form located here and return by mail or upload through this application or your student portal.

EDUCATION

Please indicate the college you attended most recently.

School Type

School One

Do you have additional schools you would like to enter?

Yes

School Type

School Two

Do you have another school you would like to enter?

Yes

School Type

School Three

Do you currently hold your Registered Nurse license?

Yes

Please upload a copy of your RN License here.

If no, when do you expect to receive it?

DEMOGRAPHICS

What is your primary citizenship?

Are you Hispanic or Latino?

Yes

Regardless of your answer to the prior question, please indicate how you identify yourself?

What is your gender?

Male

Female

If you would like the opportunity, we invite you to share more about your gender identity below.

The University of Mary Washington is dedicated to providing our military service members with as many resources as possible to assist in furthering their education. Please honor us by providing information about your service affiliation to assist us in planning.

Please tell us which branch of the service your affiliation is with.

Have you been convicted of a crime other than a traffic violation?

If yes, please describe the violation and provide the date of occurrence.

SIGNATURE

I certify under penalty of disciplinary action that the information I have provided is true. Please type your name in the box in place of your signature.

Date