First Name

Middle Name or Initial

Last Name

Suffix

Preferred Name

Date of Birth

Former Last Name

Home Phone Number

Cell Phone Number

Email Address (Please use this email with future communications with us)

Federal and state agencies request that we supply demographic data on applications for admission to Averett University. To enable us to comply with these requests, we ask that you complete this optional section. If you choose not to answer any part of this section, it will in no way affect your admission to Averett.

The VA Certifying Official for Averett University will determine the Chapter for those eligible for military benefits.

Military Status (If applicable, please select Active Duty or Veteran)

Active DutyVeteran

Marital Status

First Generation Student

YesNo

Religion

Do you intend to file a FAFSA?:

YesNo

Are you of Hispanic/Latino Ethnicity or Descent

YesNo

Select one or more races with which you identify yourself:

Start Term :

Start Year

Please select your program of interest:

Current Advanced Practice Certifications held:

BLSACLSPALSNone

Please provide us with current degrees held:

How many years of experience do you have as an RN/BSN?

If you are currently an NP, please provide number of years experience as an NP:

If you are currently an NP, what type of practices do you have experience in?

Begin Date

End Date

Begin Date

End Date