Ira D. Pruitt Division of Nursing

Social Security Number


Optional:  in accordance with the Privacy Act of 1974, you are not required to give your Social Security Number.
FULL LEGAL NAME
*Last Name
*First Name
*Middle Name
Date of Birth      
Sex
Ethnic Origin
  (Ethnic origin and Date of Birth information is voluntary and will not be used in a discriminatory manner.)
PERMANENT ADDRESS
*Address  
*City  
*State  
*Zip   (example - 35470)
MAILING ADDRESS
Address
City
State
Zip (example - 35470)
Home Phone
Cell Phone
Email
EMERGENCY CONTACT
Contact Name
Address
City
State
Zip (example - 35470)
Phone
ENROLLMENT INFORMATION
Applications are now being accepted for Spring 2019 and 2020 enrollment. 
Desired Semester of Admittance  Year*
HIGH SCHOOL INFORMATION
High School
Location
Dates of Attendance
Diploma Earned

High School
Location
Dates of Attendance
Diploma Earned
COLLEGE INFORMATION
List all Colleges attended: (If you have previously attended UWA, please list below:
College
Location
Dates of Attendance
Degree Earned

College
Location
Dates of Attendance
Degree Earned
ADDITIONAL INFORMATION
Have you previously submitted an application to the University of West Alabama?
Have you had previous education in nursing?
If yes, describe:
Have you even been convicted of a felony other than a minor traffic violation?

Transfer students are required to send additional official transcripts from all attended institutions to the Division of Nursing, The University of West Alabama, Station 28, Livingston, AL  35470.  This is in addition to required transcripts from the Admissions Office.

It is the applicant's responsibility to ensure that official transcripts from all schools attended are received by the Division of Nursing.

By clicking SUBMIT, I hereby affirm that all information supplied on this form is complete and accurate.  I understand that withholding information requested or giving false information may make me ineligible for admission and is reason for termination with loss of credit.


Home

Equal Opportunity Institution:  The University of West Alabama is an equal opportunity institution whose programs, services, activities, and operations are without discrimination as to sex, race, color, or national origin, and are open to qualified handicapped persons.