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Associate Degree Nursing Program Application

Application Deadline May 1, 2021

If you have not filled out a Belmont College application, please do so before filling out the nursing application.

Personal Data
Full Name:
Studend ID:
Mailing Address:
Zip Code:
Preferred Phone:
Alternate Phone:
Email Address:

Please acknowledge all requirements:
High School Graduate or GED
Be at least 18 years of age as of the first day of fall semester.
GPA at Belmont College is a 2.5 or higher.
Complete BIO2110 & MAT1110 with a C or higher and within the last three years and previously completed PSY1120. Prior college courses will be reviewed for possible transfer to determine equivalency or substitutions for the above courses.
Following acceptance to the program submit a copy of current STNA Registry number or PCT with National Registry number to the nursing department.
Following acceptance to the program submit State of Ohio BCI&I and FBI background checks to the nursing department that has been completed within 12 months from date of application.
Will take or have taken the nursing entrance exam prior to the application deadline.
Complete all admission requirements by the deadline for admission. Students may be provisionally accepted pending completion of summer 2021 courses and admission requirements. Ranking points are not awarded for courses completed after spring semester.
Academic Information
List all schools, colleges, or universities you are attending or have previously attended.
Name of High School:
Graduation Year:
Name of higher education school and address (City, State, and country if outside US)
Dates Attended:
+ Add another school

Have you been admitted as a nursing student at Belmont College or any other nursing programs?
If yes, what nursing school did you attend and for what semesters / years?
Nursing School:
Semesters / Years:

Have you received a non-passing grade or unsatisfactory in any nursing courses?

Do you hold or have held ANY OTHER professional or occupational licensure or certification?

Provide the following information: for STNA or PCT and CPR from the American Heart Association.
Type of Licensure / Certification:
Number Issued:
+ Add another licensure / certification

Has a complaint ever been filed against the above listed license(s) or certification(s)?

Has action ever been taken against the above license(s) or certification(s)?

Ohio Board of Nursing requires a report that validates the applicant has not been convicted of, has not plead guilty to, and has not had a judicial finding of guilt for violating the following sections of the Ohio Revised Code or similar law of another state, the United States, or another country.

Aggravated Murder; Murder; Voluntary Manslaughter; Felonious Assault; Kidnapping; Rape; Aggravated Robbery; Aggravated Burglary; Sexual Battery; Gross Sexual Imposition; and Aggravated Arson.

The above mentioned crimes are automatic bars to licensure. The Board may deny an application for the following:

  • Any felony
  • A crime involving gross immorality or moral turpitude
  • A misdemeanor drug law violation
  • A misdemeanor committed in the course of practice

If a student has been convicted of or pled guilty to any one of the following disqualifying offenses (or any substantially equivalent offense in any state), the student cannot participate in clinical education experiences.

House Bill 327 - Felony Preclusion Bill
This bill is an initiative to identify applicants for licensure with felony convictions. The Ohio Board of Nursing has the authority in this law to refuse to grant licensure to applicants with any of the felony convictions specified in the law. The law requires a criminal records check for new applicants for licensure. Candidates who wish to sit for the NCLEX RN or PN examination will be required to submit their fingerprints to the Bureau of Criminal Identification and Investigation (BCI&I) and the FBI for identification and criminal background verification.

If answering YES to ANY of the questions below please email Karolyn Fox, Director of Nursing at to provide an explanation and certified copies of related court documents if applicable.

Have you EVER been convicted of a felony or a misdemeanor or pled nolo contendere to any crime, or been pardoned?

Have you ever or are you currently abusing prescription or over-the-counter medication?

Have you ever or are you currently using illegal drugs?

Is there any reason why your access to narcotics or substances of abuse should be restricted or limited?

Do you currently possess any condition which may in any way impair your ability to practice or to otherwise alter your behavior as it relates to the practice of professional nursing?

If you hold a professional or occupational license or certificate of any kind, has your practice ever been monitored for any reason through disciplinary action or otherwise, by any facility, board, or group?

I understand that missing requirements will be communicated to me through Belmont College email ONLY and that I am responsible for checking this account regularly. If I am not a current student of Belmont College, communications will be conducted only through the email supplied by me.

I understand that applicants will be required to submit to drug testing upon entry into the nursing program and randomly thereafter, if requested by Nursing faculty, Director of Nursing and/or clinical facility.

Upon acceptance into the Associate Degree Nursing program I will purchase CastleBranch from the campus bookstore. CastleBranch is an electronic tracking system for the student's healthcare needs, licensures, and completed education.

I hereby authorize Belmont College to release a copy of my BCI & FBI background checks to any clinical site where I am assigned during my enrollment in nursing courses.

I have provided true, correct and complete information. I have read and understand the information provided in the application. I realize that any false or misleading information on this application will be grounds for denial of admissions or dismissal from the nursing program.

Digital Signature of Applicant:

This application must be received by the Academic Specialist for Health & Public Services by 4:00 PM, May 1, 2021 to be considered for admission to the Fall 2021 Semester.

FYI: The nursing program mandatory information meeting with Karolyn Fox, Director of Nursing will be held on July 9, 2021 at 8:00AM. The nursing programs mandatory orientation with the nursing faculty will be held August 19, 2021 with time to be determined.

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Students: Check your email for important course information.