APPLICANT INFORMATION
Legal Name -
(Begin with) Last Name:
First Name:
Middle Name:
Preferred Name:
Maiden Name:
Social Security Number:
Local Address:
City / County:
State:
Select from list below:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Dist of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip:
Home Phone Number:
(
)
Work Phone Number:
(
)
Email Address:
Permanent Address:
City:
State:
Select from list below:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Dist of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip:
Country (if not USA):
City Code:
Emergency Contact:
Emergency Phone:
(
)
Date of Birth:
Place of Birth:
State of Birth:
Are you a U.S. Citizen?
Yes
No
If not, are you a permanent resident?
Yes
No
Do you have an F-1 Visa?
Yes
No
Alien Registration Number:
TOEFL Test Date:
Score:
Are you a veteran?
Yes
No
* Sex:
Female
Male
* Religion:
Select from list below:
Roman Catholic
Baptist
Episcopalian
Presbyterian
Methodist
Church of Christ
Lutheran
Jewish
Other (please specify)
Religion (if "other"):
* Race:
Select from list below:
Caucasian
African-American
American Indian
Hispanic
Asian or Pacific Islalnder
Other (please specify)
Race (if "other"):
* Marital Status:
Single
Married
Divorced/Separated
* You are not required to give us this information. It is used in compiling institutional/
federal/state data and is NOT a factor in the admissions decision .
Will you be applying for financial aid?
Yes
No
Have you ever applied to Aquinas College before?
Yes
No
Year of Application
ENTRANCE TERM
Year:
Fall (Aug)
Spring (Jan)
Summer
PROGRAM OF STUDY
Bachelor of Arts
Major - Liberal Arts:
Minors:
English:
Philosophy:
History:
Theology:
Psychology:
Business:
Associate of Arts,
Liberal Arts:
Business Administration intent (B.B.A.):
Bachelor of Science in Interdisciplinary Studies
(elementary education license):
Post-Baccalaureate Licensure (Tennessee elementary teacher license):
Nursing intent (A.S.N.):
Bachelor of Science in Nursing (must be a registered nurse):
APPLICANT STATUS
I am applying as a:
Select from list below:
Re-admit
Non-degree
Freshman
Transfer
Transient (Enrolled elsewhere)
Audit (Not for credit)
I am applying as a:
Part-time student
(1-11 semester hours)
Full-time student
(12 or more semester hours)
Do you plan to graduate from Aquinas?
Yes
No
EDUCATIONAL BACKGROUND
Name of High School:
City:
State:
Zip:
Date of Graduation:
ACT/SAT Test Date:
Score:
Did you send these scores to Aquinas?
Yes
No
Did you take the GED?
Yes
No
Test Date:
Score:
List ALL colleges and professional schools attended
(include current enrollment and enrollment over 10 years):
Institution 1:
Name:
Location:
Dates:
Institution 2:
Name:
Location:
Dates:
Institution 3:
Name:
Location:
Dates:
Institution 4:
Name:
Location:
Dates:
Institution 5:
Name:
Location:
Dates:
If your name will appear differently on any of the transcripts, please indicate how:
FAMILY
Father's Full Name:
Address:
City:
State / Zip:
Select from list below:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Dist of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Home Phone Number:
( )
Work Phone Number:
( )
Occupation:
Company:
Mother's Full Name:
Address:
City:
State / Zip:
Select from list below:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Dist of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Home Phone Number:
)
Work Phone Number:
( )
Occupation:
Company:
Are you related to an alumnus of Aquinas College, Overbrook, St. Cecilia Academy, or a Dominican
Sister of St. Cecilia Congregation? If so, please list name and relationship:
Name:
Relationship:
Name:
Relationship:
Name:
Relationship:
Name:
Relationship:
ASN APPLICANTS ONLY
I have completed/am completing the following high school courses:
Introduction to Computers:
Algebra I:
Algebra II:
Chemistry:
I have completed/am completing the following college level courses:
Introduction to Computers:
Chemistry:
General Biology:
Math:
Anatomy & Physiology I:
Anatomy & Physiology II:
Have you ever been enrolled in a nursing program? (RN or LPN):
Yes
No
Name of School:
Dates of Attendance:
Reason for Leaving:
If you are a LPN, Name of School:
Date license first issued:
BSN Applicant Only
(must be a registered nurse)
Are you a registered nurse?
Yes
No
Name of Nursing School:
Expiration date of current TN nursing license:
Current Employer:
All Nursing Applicants
Have you ever been convicted of a felony or misdemeanor other than a minor traffic violation?
Yes
No
Have you ever been involved in a disciplinary action because of use, possession, or sale of a controlled substance?
Yes
No
Have you ever had your nursing license revoked/suspended?
Yes
No
Are you receiving or have you ever received treatment for any physical or emotional/mental problem which has interfered
with or which may interfere with your ability to practice nursing?
Yes
No
If you answered yes to any of the above questions, please attach a
letter of explanation.
The Tennessee Board of Nursing may deny licensure to anyone who:
has been convicted of a crime
is unfit or incompetent by reason of negligence, habits, or other causes
is addicted to alcohol or drugs to the degree of interfering with nursing duties
is mentally incompetent
is guilty of unprofessional conduct
ALL APPLICANTS
By checking this box, I certify that all information on this application is accurate and true, and understand that
misrepresentation can lead to dismissal from the nursing program. I also understand the legal limitations regarding
licensure set forth by the Tennessee Board of Nursing.