Date of Application
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Desired Entrance Month
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Desired Entrance Year
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Please check the appropriate box:
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First Name
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Last Name
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Middle Name
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Other/Maiden Name
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Address
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City
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State
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Zip
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Primary Phone
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Alternate Phone
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Email
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Social Security Number
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Date of Birth
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Age
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Gender
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U.S. Citizen
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Ethnic Group
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I am a person with a disability
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I am a veteran
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Provide information concerning high school graduated from or high school equivalency (HiSET/GED)
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Highschool Graduation Month/Year (MM/YYYY)
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Upload High School transcript or High School equivalency scores
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Provide information concerning any college, university, or any other school attended
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Please zip and attach all transcripts (including Eastern). LPN and EMT must include vocational transcript
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Are you currently a state certified CNA, LPN, or EMT?
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If you have ever attended any RN school, provide the following information:
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Name of school
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city and state
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month/year of entrance
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reason for leaving *If transferring from another school of nursing, a reference letter from a dean or nursing faculty is required.
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If you feel that there is additional information needed to further explain any item on your nursing application, please upload your explanation as a separate page with this application.
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A national background check by QualifiedFirst by Verified Credentials, Inc. is required with this application. Please see separate instruction sheet included in the packet. This will be at the cost of the applicant and must be done within 90 days prior of application to the nursing program. Please be aware the background results may take a week or more to process
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Background Check Instructions
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Students applying for the transition program, must submit verification of 800 work hours. Please contact your nursing advisor or the nursing office to confirm your verification
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In compliance with Oklahoma State Board of Nursing Registration and Nursing Education, the following information is necessary in order to take the National Council Licensure Examination for licensure as an RN.
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Students applying for readmission to Eastern’s nursing program, must address, in writing, their exit interview action plan(s).
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Have you taken the examination for registered nurse licensure in any other state?
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Have you been licensed in any state as an LPN/LVN or EMT-P?
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If yes, which state
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Is your licensure currently unrestricted?
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provide verification from each state
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Indicate name on license (if different than application):
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Have you ever had any action taken by a State Board of Nursing (LPN) or licensing body (EMT-P) regarding licensure?
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Have you ever been arrested, convicted, or charged of a crime?
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*Omission of information or falsification can result in non-acceptance. Please include all such incidents no matter how minor the infraction, whether guilty or not.
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Please see the Oklahoma Board of Nursing rules in reference to felonies.
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Have you ever been judicially declared incompetent
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Do you have any physical limitations/disabilities that may interfere with your clinical performance?
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If you answer YES to any of the above questions, you must submit details on a separate page or your application will not be reviewed.
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According to the Oklahoma Board of Nursing, “An individual with a felony conviction or who had sentencing terms imposed by the court related to a deferred sentence for a felony offense cannot apply for licensure for at least five years after completion of all sentencing terms, including probation and suspended sentences, unless a presidential or gubernatorial pardon is reviewed [59 O.S. § 567.5 & 567.6
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The nursing program abides by the school’s policy regarding misconduct and
academic cheating. Have you ever been written up for misconduct or academic cheating?
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The Oklahoma Board has the authority to deny a license, recognition or certificate; issue a license, recognition or certificate
with conditions and/or an administrative penalty; or to issue and otherwise discipline a license, recognition or certificate
to an individual with a history of criminal background, disciplinary action on any professional or occupational license or
certification, or judicial declaration of mental incompetence [59 O.S. § 567.8]. These cases are considered on an individual
basis at the time application for licensure is made, with the exception of felony convictions. Potential applicants to stateapproved
education programs, with a criminal history, may obtain an initial determination of eligibility for licensure or
certification from the Oklahoma Board of Nursing for a fee. The initial determination of eligibility for licensure petition can be
accessed at:
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Instructions and petition to request initial determination of eligibility for licensure or certification for individuals with history of criminal conviction
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The Nursing Advisor I met with prior to submitting my application. (The Nursing Advisor list can be found at <a href='https://www.eosc.edu/academics/explore-programs-majors/health' style='color: blue' target='_blank'>Nursing Faculty</a> or calling 918.465.1794.)
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Campus Selection Form
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Please print the physical qualification form, sign, date and attach.
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Physical Qualification Form(required).
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