Undergraduate - Nursing Professional Experience

The information that you provide here will give us a deeper understanding of your academic and professional background. Please note: SUNY policy prohibits campuses from inquiring into an applicant's prior criminal history. After acceptance, the college will inquire about this if a student seeks participation in clinical or field experiences. Students who have previously been convicted of a felony are advised that their prior criminal history may impede their ability to complete the requirements for certain professions. Students who have concerns about such matters are advised to contact the office of the Vice President for Student Affairs at 315-792-7505.

First Name

Last Name

Email

Birthdate

Nursing Program

Professional Experience

Identify how many years you have been licensed as a registered professional nurse:

Family Nurse Practitioner Applicants: How many years of clinical experience do you have?

Nursing Education Applicants: How many years of educator experience do you have?

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Current professional position and employment history (list current position first). Add Additional Jobs Below
Employer Name & Address Job Title Date of Employment Date of Employment Description of Duties

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What certifications do you hold (excluding CPR, PALS, ACLS)?

List any committees within your workplace that you currently serve on:

Do you hold a leadership position on any of these committees?

Yes

No

Please List:

Professional Activities

What professional associations do you hold memberships with? List any leadership roles that you hold:

List any community service activities that you participate in:

Are you a member of Sigma Theta Tau (International Honor Society of Nursing)?

Yes

No

Research & Scholarly Activities

Are you currently engaged in research and scholarly activities?

Yes

No

List any scholarly papers that you have published or presented:

Have you participated in any grant writing activities?

Yes

No

List any grants that you have been awarded:

Have you participated in research projects?

Yes

No

Please describe:

Licenses

Please list all licenses/registrations in all jurisdictions and/or states in which a license/registration is or has ever been held, including any registrations through occupational licensing boards or emergency medical services that you hold or have ever held. This includes any active or inactive licenses/registrations that have been encumbered, disciplined, sanctioned or terminated at the time of this application.

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License/Registration State License/Registration # Expiration Date Expiration Date

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