Personal Information

*First Name:     Middle:

*Last Name: (Maiden):

*Address:

*City: *County: *State: *Zip Code:

*Home Telephone: *Social Secuirty No.: (111-11-1111)

Business

*Employeer: *Present Position:

*Address:

*City: *County: *State: *Zip Code:

*Business Telephone: *E-mail Address:

*Date of Birth: mm/dd/yyyy *Sex: M F | *Marital Status: Single Married

Ashland University admits students with handicaps and those of any sex, race, age, religion, color and national or ethnic origin. In order for the University to respond to required state and federal questionnaires, you are asked to assist us, on a voluntary basis, by responding to the following:

Race: Amercan Indian/Alaska Native White Hawaiian/Pacific Islander Black/African American Asian

Education
Listed in chronological order School of Nursing and/or all colleges attended:
School/ Area of Study/Degree Conferred

*School *Area of Study

*Degree Conferred *From *To

School Area of Study

Degree Conferred From To

EMPLOYMENT RECORD (List in chronological order starting with most recent. List additional information on the back of form.)
Employer/Location/Position

*Employer *Location

*Position *From *To

Employer Location

Position From To

VERIFICATION
I hereby certify that the above information is accurate and complete. I understand that any misrepresentation of facts on this application could be cause for suspension from the university. Additionally, I agree to adhere to the conduct norms of the campus community and all policies/regulations of Ashland University.

Ashland's policy is to release your name, address and basic attendance information to persons who inquire from outside the university. If you do not wish us to release any information you must notify the Registrar's Office and the Department of Nursing in writing.

I have read and understand the terms and agreement stated by Ashland University.