WIXLIB

CAMC Health Education and Research InstituteCAMC School of Nurse Anesthesia3110 MacCorkle Ave., SERobert C. Byrd Building, Room 2041Charleston, WV 25304Phone 304-388-9950Fax: 304-388-9955Preference will be given to applications receivedbefore October 1October 1 for 1st Admissions CommitteeFebruary 1 for 2nd Admissions CommitteeFor classes starting in May 50.00

CAMC/Marshall University DMPNA Nurse AnesthesiaApplication Checklist 1. Completed CAMC SCHOOL OF NURSE ANESTHESIA APPLICATION2. Application Fee of 50.00 (payable to CAMC School of Nurse Anesthesia)3. Copy of current nursing license(s)4. Resume5. Photocopy of GRE Scores6. Completed CAMC Reference Request Form7. Official College Transcripts (sent by each College and/or University)CAMC must receive transcripts from every schoolattended, even if credit was transferred to anotherinstitution.Items 1-7 above above should be sent to:CAMC School of Nurse AnesthesiaAttn: Admission Committee3110 MacCorkle Avenue, S. E.Robert C. Byrd Building – Room 2041Charleston, WV 25304 8. Completed GRADUATE APPLICATION FOR ADMISSION TO MARSHALLUNIVERISTY 9. Application Fee of 40.00 (payable to MARSHALL UNIVERSITY) 11. Official undergraduate transcript of baccalaureate degree sent directlyfrom the degree granting universityMarshall University requires only the transcriptfrom the baccalaureate degree.10. Official GRE scores sent directly to Graduate Admissions from ETS. ETScode for Marshall University is #5396Items 8-11 above should be sent to:Marshall UniversityGraduate Admissions Office100 Angus E. Peyton DriveSouth Charleston, West Virginia 25303-1600The Graduate Application for Admission to Marshall University may be completed online ORsubmitted by mail.

CAMCSchool of Nurse AnesthesiaAPPLICATIONCharleston Area Medical Center Health Education and Research Institute and the CAMCSchool of Nurse Anesthesia exercises a nondiscriminatory practice relative to age, race,creed, sex, or national origin.Charleston Area Medical Center Health Education and Research InstituteCharleston Area Medical Center School of Nurse Anesthesia3110 MacCorkle Ave., SERobert C. Byrd Bldg., Room 2041Charleston, West Virginia 25304Phone: 304-388-9950Fax: 304-388-9955

THE APPLICATION MUST BE COMPLETED IN ITS ENTIRETYTO BE PROCESSEDPlease Print For the RecordDate:Name: Telephone: Home:LastFirstMiddleMobile:Email:Present Address:StreetCityStateZipPrevious Address:StreetCityStateZipVisa Classification if not a U. S. Citizen: Social Security No.:Have you ever been convicted of a felony? Education Yes NoName in school(s), if different from above:List ALL colleges and universities attended. If you have attended more than 5 schools, pleaselist them on a separate sheet.Name of schoolCity and StateDate enteredDate leftDegreeMonth/yearMonth/yearearned Previous Anesthesia EducationHave you ever been enrolled in a nurse anesthesia educational program? Yes No

Employment HistoryLIST LAST THREE JOBSBEGINNING WITH MOSTRECENTComplete addresses and phone numbers are required.Employer Name: Supervisor Name:Address: Telephone:Your Position: Job Duties: Part-time Full-timeDates: From: To:Employer Name: Supervisor Name:Address: Telephone:Your Position: Job Duties: Part-time Full-timeDates: From: To:Employer Name: Supervisor Name:Address: Telephone:Your Position: Job Duties: Part-time Full-timeDates: From: To: Anything to Add?Summarize any other information you believe pertinent to your application:

SignatureI certify that the answers given by me to the foregoing questions and statements are true and correct withoutconsequential omissions. I understand and agree that any misrepresentation in my application will be sufficientcause for cancellation of the application and/or separation from the school. I authorize and release from liability orresponsibility all persons, companies, schools and municipalities supplying any information regarding me whether ornot it is a matter of record. I voluntarily give the CAMC School of Nurse Anesthesia permission to make a thoroughinvestigation of my past employment and all other facts stated above. I further understand that the school mayterminate me at any time without statement of reason and I may quit the school for any reason. No contrary impliedagreement has been made to me. I further realize that acceptance to the CAMC School of Nurse Anesthesiacannot be finalized until reference information, licensure verification, and medical examination has been completed.The medical examination may involve screening for drugs or alcohol. I further realize that acceptance to the CAMCSchool of Nurse Anesthesia is contingent upon concurrent successful Marshall University Graduate admission.Signature of Applicant: Date:Thank you for applying to CAMC School of Nurse Anesthesia Reference Request and Releaseof InformationI voluntarily give Charleston Area Medical Center Health Education and Research Institute, Inc./CAMC School of NurseAnesthesia permission to make a thorough investigation of my past employment.I authorize and release from liability or responsibility all persons, companies, schools and municipalities supplying anyinformation regarding me whether or not it is a matter of record.Date: Applicant’s Signature:

CAMC References Request FormPlease list the names and addresses of three (3) people whom we may contact regarding yourqualifications to enter Nurse Anesthesia School. One reference MUST be your immediatesupervisor. A person knowledgeable of your clinical skills will be acceptable as a reference ifimmediate supervisor reference is not available.Remember!INCLUDE THIS FORM WHEN YOU SUBMIT YOUR APPLICATION TO THE CAMC SCHOOLOF NURSE ANESTHESIAApplicant’s Full Name:Reference 1Reference 2Reference 3Name:Title (if any):Name:Title (if any):Name:Title (if any):Full Mailing Address*:Full Mailing Address*:Full Mailing Address*:*If hospital, be sure to include department nameCAMC School of Nurse Anesthesia will contact the above references to completeappropriate reference forms.

CAMC/Marshall University DMPNA Nurse Anesthesia Application Checklist 1. Completed CAMC SCHOOL OF NURSE ANESTHESIA APPLICATION 2. Application Fee of 50.00 (payable to CAMC School of Nurse Anesthesia) 3. Copy of current nursing license(s) 4. Resume 5. Photocopy of GRE Scores 6. Completed CAMC Reference Request Form 7. Official College .