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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

Postdoctoral Special Studies:
Application for Admission

Please complete sections A, B, C, D, and E 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 and a current curriculum vitae, if appropriate.

See http://nurseweb.ucsf.edu/www/ps-i.htm for more information on Postdoctoral 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. Home Address

2a. Home Telephone Number (Area Code)
Fax Number

3. Office Address

3a. Office Telephone Number (Area Code)
Fax Number

4. Present Position (Title)

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: Publications
List all publications, beginning with the most recent.

Section D: Research
List all research projects in which you have had a role, beginning with the most recent. Identify your role and provide the source and amount of funding, if applicable. For the dissertation, identify the department in which the doctoral degree was granted and members of the dissertation committee, including their title.

Section E: Objectives
State your objectives for postdoctoral work, including plans for research or clinical activities.

Signature of Applicant	Date

OAP/PAPP (9/2000, 8/2006)

Postdoctoral Special Studies: Application for Admission

Postdoctoral Special Studies:
Application for Admission