College of Nursing - Associate of Science in Nursing (RN) Application 2024-2025

Personal Information

First Name:

Middle Initial:

Last Name:

List any former last name(s) you have used:

Personal Email Address:

Social Security Number:

Birthdate:

Phone Number:

Mobile Phone Number:

Mailing Address:

Country

Street

City

Region

Postal Code

Are you a current Fairmont State University student (Dual Enrollment and High School students taking college credit courses are not included)?

Yes

No

Fairmont State ID Number (if applicable):

Fairmont State University Email Address (if applicable):

Are you a US citizen?

Yes

No

Are you lawfully authorized to attend school in the United States of America?

Yes

No

Gender:

Female

Male

What is your ethnicity?

Hispanic or Latino

Not Hispanic or Latino

Regardless of your answer to the prior question, please select one or more of the following that best describes you (Required for federal reports by Civil Rights Act of 1964. Not used for admission decision):

Are you a veteran of the US Armed Forces?

Yes

No

Emergency Contact Information

In case of emergency, please notify:

First Name:

Last Name:

Phone Number:

Nursing Program Information

Do you possess an active, unencumbered LPN license (Licensed Practical Nurse)?

Yes

No

LPN License State:

LPN License #

Please upload a copy of your license from Nursys.com or your State Board of Nursing website.
If unable to upload, please e-mail a copy of your license to admissions@fairmontstate.edu.

Please choose Yes for all program(s) for which you are interested in applying:

Fall 2024 Hybrid Weekend Program

Yes

Fall 2024 LPN to ASN Program

Yes

Fall 2024 Traditional ASN Program

Yes

Spring 2025 LPN to ASN Program

Yes

Spring 2025 Traditional ASN Program

Yes

Are you a student in an LPN program scheduled to graduate prior to enrolling in the ASN program?

Yes

No

What date do you anticipate taking the NCLEX-PN exam?

Have you previously enrolled in another nursing program, taking courses but not completing the program?

Yes

No

Please provide the reason(s) for non-completion of that program:

Educational Background

High School : Enter GED, TASC or Home School if this is applicable to you.

High School Name:

Did you graduate?

Yes

No

Date of Graduation or Completion (if GED or TASC):

Have you attended college or any other post high school institutions following high school graduation? Enter all educational institutions attended since high school.
If you have attended Fairmont State University, please list it as well.

Yes

No

Post High School Education

Institution Name:

Did you graduate?

Yes

No

Date of Graduation:

Date of last attendance:

Have you attended any other schools?

Yes

No

Institution Name:

Did you graduate?

Yes

No

Date of Graduation:

Date of last attendance:

Have you attended any other schools?

Yes

No

Institution Name:

Did you graduate?

Yes

No

Date of Graduation:

Date of last attendance:

List any other educational institutions that you have attended:

If applicable, from what Institution did you receive your LPN Certificate?

Employment Information

Name of Employer:

Employer Phone:

Position Title:

Supervisor Name:

Job Start Date:

Job End Date:

Reason for Leaving:

Please briefly describe experience gained:

Do you have any other employment to add?

Yes

No

Name of Employer:

Employer Phone:

Position Title:

Supervisor Name:

Job Start Date:

Job End Date:

Reason for Leaving:

Please briefly describe experience gained:

Do you have any other employment to add?

Yes

No

Name of Employer:

Employer Phone:

Position Title:

Supervisor Name:

Job Start Date:

Job End Date:

Reason for Leaving:

Please briefly describe experience gained:

Please identify any certificates that you hold in a health-related field (CNA, Phlebotomist, EMT, Paramedic, LPN, RN, etc.):

Upload a copy of any relevant certificate(s) or your license from Nursys or your state Board of Nursing website here

Professional Conduct

The Fairmont State University College of Nursing strongly supports the standards of the West Virginia Board of Registered Professional Nurses and the American Association of Nurses. Applicants are advised that their conduct before and after submitting their application to the College of Nursing will be considered in the admission process. Irresponsible behavior or conduct denoting questionable moral character will include, but not necessarily be limited to the following:
• Criminal activities - e.g. DUI, misdemeanors, felonies
• Substance abuse - e.g. manufacture, use, distribution, positive results on drug screen
• Cheating/dishonesty
• Harassment 
• Domestic violence
• Discrimination
• Breach of patient confidentiality

Students are advised that their conduct while students both on and off campus could result in dismissal from the program.

Have you ever pled guilty or “no contest” (nolo contenders) to, or been convicted of, violating any law, with the exception of minor traffic violations?

Yes

No

Please provide a description of your prior conviction history, including date of conviction, court appearance, and details of each violation:

NOTE: Disclosure of a criminal record does not automatically disqualify you from admission consideration. The State Board of Nursing may deny eligibility to take the registered nurse licensing exam for individuals who have been convicted of a felony or misdemeanor and persons with drug/chemical dependency. Applicants are encouraged to speak with the Board of Nursing to discuss potential concerns.

Is there any reason why your access to narcotics or substances of abuse should be restricted or limited?

Yes

No

Please contact the Dean for the College of Nursing to discuss your circumstances.

Do you currently possess any conditions or take any medications which may in any way impair your ability to practice or otherwise alter your behavior as it relates to the practice of registered professional nursing?

Yes

No

Please contact the Dean for the College of Nursing to discuss your circumstances.

Has your nursing practice ever been monitored for any reason, disciplinary action or otherwise by any facility, board or group?

Yes

No

Please contact the Dean for the College of Nursing to discuss your circumstances.

Please list any medication or personal information which you feel may have an impact on your participation in nursing classes/clinical (i.e. health conditions, etc.):

Statement of Understanding

I understand the following:

It is my responsibility to contact the Office of Admissions at 304.367.4141 to ensure that my official transcripts and records are received, accurate and complete upon acceptance.
Travel is required in the Nursing programs. Day, evening, night, and/or weekend clinical rotations may be assigned. All arrangements and expenses are my responsibility.
Background checks, both criminal and personal, and drug screens are required at my expense upon acceptance into a program. Following admission information will be provided to you about the background check and drug screening process. Payment and testing are required regardless of previous acceptance into a program(s). Previous background checks and drug screens are not acceptable.
A random drug screen may be requested at any time while in the program. Failure to comply with a request for a drug screen, or a positive or diluted drug screen, or tampering with results, will result in immediate dismissal from the program.
At the discretion of certifying/licensing agencies, clinical agencies can require the results of background checks, drug screens, or other investigative information and can prohibit access to clinical facilities.
I may or may not be allowed to take the appropriate licensure/certification exam after completion of a program if convicted of a felony or misdemeanor.
If I have ever received, or am currently receiving, treatment for drug dependency, I must submit a copy of the treatment/record or discharge summary, printed on the facility’s letterhead upon tentative admission to the Nursing program to the Dean for the College of Nursing.
If I believe a prescription medication prescribed by my healthcare provider may affect my performance, I will consult with the Dean in the College of Nursing.
Letters of recommendation ARE NOT required and, if submitted, WILL NOT be used in the selection process.
Applications are not held over from year to year and if I am not admitted I must re-apply.
Failure to provide any requested information or any proven misrepresentation, dishonesty, deceit, falsification, or omission of information WILL result in immediate disqualification of the application.
If any of the above statements are not fully understood, it is my responsibility to request clarification from the College of Nursing.
Full admission to the College of Nursing is contingent upon results of background check, drug screen, and completion of health data and clinical agency requirements by the notified due date. Failure to meet the due date for submission of requirements may results in dismissal from the nursing program.
Immediately following completion of the application, persons with disabilities or needing accommodation should contact the Office of Accommodation and Services to plan for potential accommodation. The Office can be contacted at 304.333.3661. Information provided to the Office of Accommodation and Services is considered confidential and is not disclosed without the written permission of the student.

Please provide your initials below to acknowledge that you have read and understand the Statement of Understanding:

Student Initials

Statement of Truth

I certify the information I have supplied in this application is complete and true and understand that any omission or misrepresentation of fact may result in denial of acceptance or dismissal from the School of Nursing. I understand that I must successfully complete all aspects of clinical agency requirements by the date identified in my provisional letter of admission which is a condition of my acceptance.

Please provide your full name and today's date below. By typing your full name you accept its use as your electronic signature and agree to the Statement of Truth.

The ASN program meets the requirements for initial licensure, following graduation, as an RN in WV.  Some states may have additional licensure requirements for new graduates.  Students who plan to obtain their initial licensure in a state other than WV should review the information posted on our website entitled Licensure Disclosure (https://www.fairmontstate.edu/admit/licensure-disclosures ) to make sure that the program will meet the requirements for the state in which you want to sit for your initial licensure.

Student's Full Name:

Date:

Before any application is considered, the University must have received transcripts from all institutions attended (high school, college, and other), ACT or SAT scores unless it is over five years since you graduated from high school, GED scores when applicable and TEAS scores. All transcripts must be official and sent directly to the Office of Admissions.

Fairmont State University is an equal opportunity, affirmative action institution.