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Ogden-Weber Applied Technology CollegePRACTICAL NURSING PROGRAM APPLICATION CHECKLISTApplication Guidelines:Complete the following checklist. It is your responsibility as the applicant to ensure that all items arecompleted.The completed application packet can be mailed to: 200 N Washington Blvd, ATTN: Cashier, Ogden,Utah 84404 or be submitted in person to the cashier’s window Monday through Friday, 9:00 a.m. - 4:00p.m. THE REQUESTED DOCUMENTS MUST BE POSTMARKED ON OR BEFORE MARCH 1 FORFALL ADMISSION.Turn in the application packet only when all of the information, forms, transcripts,and reference letters are in the packet.Please note that any missing information/forms not included in the packet will render yourfile incomplete, and you will not be considered as a possible candidate for this program.Please initial or place N/A in each of the following boxes and sign and date on page 2. Include this checklistas part of your application.I have fully completed, signed, dated, and returned the OWATC Application Form.I have fully read, signed, dated, and returned the OWATC PNP Disclaimer.I have submitted a copy of my High School Diploma or High School Transcript or GED Certificate.This is required to verify high school completion for state testing requirements by DOPL.Verification of all prerequisite classes must be documented via: Official College or Universitytranscript, AP testing Score Sheet or High School Transcript, or Accuplacer Score Sheet.I have submitted all current official transcripts, received either by mail or in person in a sealed officialenvelope, by the application deadline. OFFICIAL TRANSCRIPTS FROM THE ORIGINAL SCHOOLARE REQUIRED EVEN IF THE CREDITS HAVE BEEN TRANSFERRED. CLASS NAMES DO NOTSHOW ON THE OFFICIAL TRANSCRIPT OF THE TRANSFERRED TO SCHOOL. Attach proof ofofficial transcript request to any unofficial transcript submitted. Web page printouts will not be accepted.I understand that in order to receive application points for prerequisite courses, these courses must becompleted with a grade of “C” or better.I am submitting transcripts from another state, and I have provided a course description for eachcourse so it can be determined if transfer credit can be given. I understand that I only need to submitcourse descriptions for the prerequisite courses I want to transfer. Please complete the informationbelow for prerequisite courses only.Example:Intermediate Algebra 105 course taken at University of Calif. should transfer for Math 1010course taken at should transfer forUpdated 11/19/14

I understand that IF OWATC will not accept my out-of-state prerequisite courses for transfer credit,that I will need to retake those courses. (Please contact an OWATC counselor prior to applicationdeadline if you have questions on course transfers).I have a cumulative Grade Point Average of 2.7 or higher.I have submitted an Accuplacer Score Sheet if placed in Math 1030, 1040, or 1050.I have submitted Current Nursing Assistant Certification from the State of Utah or Current Notice ofNursing Assistant Certification Renewal from the State of Utah OR must submit proof of currentenrollment in CNA course. Certification must be received prior to beginning the PN Program. Contactthe CNA Utah Registry (801)547-9947 for any questions.I have submitted verification of work or volunteer experience for all direct patient healthcare.Please provide a letter from a Human Resources representative or supervisor with your job title, jobdescription, and dates of employment on company letterhead. A company printout of positions anddates, or website requests for this information, will not be accepted.I have included three completed OWATC reference forms. Each reference form must be completedIN FULL by either a current or past supervisor or instructor, not co-workers. Please select evaluatorsthat can respond to all criteria on the reference form. Otherwise, you will only receive points forthe categories scored. ALL REFERENCE FORMS MUST BE SUBMITTED WITH THEAPPLICATION PACKET. References must include your name on the front of the envelope and must besigned across the envelope seal from the person completing the reference. (Use OWATC referenceforms only, references on any other school’s form will be disqualified).I have paid or enclosed the 25.00 application fee payable to OWATC. Payments can also be paid atthe cashier’s window in person (Monday through Friday, 9:00 a.m. - 4:00 p.m.). The receipt must beincluded in the application packet. I understand the application fee is non-refundable and used toprocess my application. Applications without a receipt of payment will be disqualified.I understand that if I am accepted into the program, or a top ten alternate, I will be required to have asatisfactory National Criminal Background Check and Sex Offender Check.I have completed, initialed, or placed N/A on every line of the application checklist and submitted allforms requested. I understand that failure to provide the above information by the application deadlinewill render my file incomplete and disqualified.If you have any questions regarding the application packet, please call 801-627-8351.Signature of ApplicantUpdated 11/19/14Date

Application for AdmissionPractical Nursing Program1. Full NameLastFirstMiddle InitialMaiden Name2. Mailing AddressNumber and StreetCityStateZip Code3. Home AddressNumber and Street4. Telephone # (CityState) () (Home PhoneCell PhoneZip Code)Work Phone5. Social Security #6. Person to be notified in case of emergency:RelationshipTelephone # ()AddressNumber and StreetCityState7. Please provide information concerning high schools, technical schools and colleges you haveattended. Include any you are currently attending, and begin with most recent.Name of SchoolCity and StateDates Attended(mo/yr)Major or EmphasisDiploma or Certification

8. Please provide information about your health-related employment. Include any paid positions youhave held in the health care field. Attach letters of proof of employment. (A letter from HumanResources with your job title and dates of employment on letterhead is sufficient). (Print out fromHR database will not be accepted.)Name of EmployerCity and StateDates of employment(mo/yr)Position HeldSupervisorand Phone Number9. List all other employment. Include any paid positions you have held that were not listed above.Name of EmployerCity and StateDates of employment(mo/yr)Position HeldSupervisorand Phone Number10. Please list your volunteer experience. Include any practicums or on-the-job training.Name of EmployerCity and StateDates of employment(mo/yr)Position HeldSupervisorand Phone Number11. Please list your extracurricular activities, awards, honors, scholarships, etc. Include any otheractivities you have been involved in the past 5 years.

12. Satisfactory progress through the Practical Nursing Program requires regular attendance in classand clinical, as well as study time outside of class. Clinical hours may include evenings andweekends. Are you willing to commit to the prescribed hours and course study?13. Optional Data (for statistical purposes only)Ethnic BackgroundBlack non-HispanicAsian or Pacific IslandHispanicWhite non-HispanicNative AmericanOtherGender:MaleFemale14. Note: To be licensed as a Practical Nurse in the state of Utah, the application must be inconformity with the Utah Nurse Practice Act. Applicants who have been convicted of a felony,treated for mental illness or substance abuse should discuss their eligibility with the Utah StateBoard of Nursing (801-530-6628). Acceptance and completion of the OWATC Practical NursingProgram does not assure eligibility to sit for the practical nursing licensure exam. The Utah StateBoard of Nursing makes the final decisions on issue of license to practice nursing in the state ofUtah.I do hereby certify the statements in this application are true and complete to the best of myknowledge. I understand that falsifying information on this application may be grounds fordismissal.SignedDate“Diversity encompasses acceptance and respect which means understanding that each individual is unique, and recognizing and appreciating ourindividual differences.”In compliance with the American with Disabilities Act, persons needing auxiliary communicate aids and services should call the Office ofDiversity at (801)627-8452(TDD number (801)627-8308), allowing at least 48 hour advance notice.

Ogden-Weber Applied Technology CollegePractical Nursing Program Disclaimer Admission to the Ogden-Weber Applied Technology College (OWATC) Practical NursingProgram is contingent upon submission of a satisfactory FBI Background Check, Sex OffenderCheck, and negative drug screen. If you have a record of criminal actions, it may affect youreligibility. Applicants/students who have committed felonies and have not met the stated criteria in theUtah Nurse Practice Act Subsections 76-3-203.5(1)(c) and 76-3-203.5(1)(c) will not beallowed to enter/progress into the OWATC Practical Nursing Program. Admitted applicants/students are required to inform the Practical Nursing Program Manager ofany criminal charges they may have pending against them. Accepted applicants/students whohave falsified or withheld information regarding pending criminal charges will be not be allowedto enter/progress into the OWATC Practical Nursing Program. Admitted applicants/students who have been treated for mental illness or substance abuse shoulddiscuss their eligibility status with the Utah State Board of Nursing. Acceptance to the nursingprogram does not assure eligibility to write the PN or RN licensing examination. The UtahBoard of Nursing makes final decisions on issue of licensure. The OWATC Practical Nursing Program is a rigorous two-semester program. Pleasecarefully evaluate your situation and do all you can to allow your studies to be a majorpriority. Full-time employment while in the program is not recommended. Pre-requisite courses must be completed with a “C” or better prior to beginning the PracticalNursing Program. Admitted applicants/students who are suspended or withdrawn from the OWATC PracticalNursing Program may not be entitled to reimbursement of tuition or other fees. Students accepted into the OWATC Practical Nursing Program may be exposed to blood-bornepathogens during their time in the program. “Diversity encompasses acceptance and respect which means understanding that each individualis unique, and recognizing and appreciating our individual differences.” The College will not tolerate any form of harassment and acknowledges that such conduct willbe grounds for immediate and appropriate disciplinary action. The College will comply with allfederal, state, and local laws on these issues. The College is committed to providing anenvironment free from harassment and discrimination. Such an environment is a necessary partof a healthy learning and working atmosphere. Harassment and discrimination undermine thesense of human dignity and sense of belonging of all people in an environment.I have read and understand the OWATC Practical Nursing Program Disclaimer information.Student Signature: Date:In compliance with the American with Disabilities Act, persons needing auxiliary communicate aids and services should call the Office OfDiversity at (801)627-8452(TDD number (801)627-8308), allowing at least 48 hour advance notice.Updated 7/30/2014