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School of Nursing
Office of Academic Programs
2 Koret Way, #N-331B
UCSF Box 0604
San Francisco, CA 94143-0604

Telephone: (415) 476-2595
Fax: 415-476-9707

Special Studies:
Application for Admission

Please complete sections A, B, C, and D below (type or print) and return the completed application to the Office of Academic Programs, together with a letter of reference attesting to your professional abilities.

See http://nurseweb.ucsf.edu/www/ps-i.htm for more information on Special Studies programs at the School of Nursing, University of California, San Francisco.

If English is not your first language, an official copy of your TOEFL score must be provided. International applicants also must submit the Confidential Financial Statement form.

Section A: Personal Information
1. Full Legal Name
2. Current Address
3. Permanent Address
4. Telephone Number (Area Code) Fax Number
5. E-mail address
6a. Citizenship, Citizen of (Country) Visa Type (e.g., J-1, F-1, B-2, or LPR for Perm. Resident)
6b. Place and Date of Birth Birth Place (City, State, Country) Birth Date (mm/dd/yyyy)
7. Social security number (if applicable)
8. Are you licensed as a registered nurse (RN)? State or Country
9. If you have applied to the UCSF School of Nursing before, indicate: When? Under what name?
10. When do you want to study? If you will be studying for at least one quarter, please adhere to the academic calendar for the intended study period. Beginning date Ending date
11. Health insurance is required of all students. Indicate whether you will be covered by: [ ] UCSF Student Health insurance, or [ ] Other health insurance coverage
12. The Test of English as a Foreign Language ( http://www.toefl.org ) is required for those applicants who are not native speakers of English. Please provide the test date and official score. TOEFL date TOEFL score

Section B: Educational Record List - in chronological order - all schools or colleges attended since high school.
Name of School		Location
Dates of Attendance	Beginning	Ending
College degree (major), diploma, or certificate		Date Awarded
Name of School		Location
Dates of Attendance	Beginning	Ending
College degree (major), diploma, or certificate		Date Awarded
Name of School		Location
Dates of Attendance	Beginning	Ending
College degree (major), diploma, or certificate		Date Awarded
Name of School		Location
Dates of Attendance	Beginning	Ending
College degree (major), diploma, or certificate		Date Awarded

Section C: Nursing Experience List each position chronologically, beginning with the most recent.
Dates
Agency	Location
Position	Clinical Area
Dates
Agency	Location
Position	Clinical Area
Dates
Agency	Location
Position	Clinical Area
Dates
Agency	Location
Position	Clinical Area

Section D: Proposed Study Plan
1. Briefly describe why you are applying to the Special Studies program and indicate what specific educational or professional goals you hope to attain upon completion of study.
2. Identify the courses you want to take.
3. Identify clinical or field observations you desire.
4. Identify any other information that would help in planning your program.
5. Do you anticipate any time in patient contact or observations in patient care areas? [ ] Yes [ ] No
Signature of Applicant	Date

OAP/APP (9/2000, 8/2006, 8/2007)

Special Studies: Application for Admission

Special Studies:
Application for Admission