Please mail; Fax; or this application to the address listed above along with a $50.00 application fee made payable to

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Missouri State School of Anesthesia RN to DNAP

Professional 400, 901 S. National Ave- Springfield, Mo. 65897 Phone: 417-836-5039: Fax: 417-836-3225

Please mail; Fax; or email this application to the address listed above along with a $50.00 application fee made payable to

“Missouri State School of Anesthesia”

Full Name: _________________________________________________________________

Last First Middle

Address: _____________________________________________________ _____________________________________________________

Phone: ________________________________ SSN: ___________________________________

Email: _________________________________ Nursing Lisc: _____________________________

Nursing Program ____________________________________________________ Completion Date________ Bachelors’ Program __________________________________________________Completion Date________ Degree Conferred: ________________________________________ (BS; BSN etc)

Have you previously applied to this program? ________________

Please provide answers to the following questions:

Have you ever been admitted to and then released from any other schools of anesthesia? __________

If yes please explain the circumstances __________________________________________________________

Have you ever had you license suspended or revoked? ____________ if yes please explain ________________ __________________________________________________________________________________________ Please provide a full criminal history, excluding traffic offenses _______________________________________ __________________________________________________________________________________________

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NOTE: Application with related material (To include Transcripts) Become the Property of the

Missouri State School of Anesthesia and will not be returned to the Applicant.

Please complete all of the items on the APPLICATION CHECKLIST! It is your responsibility to

make sure all the items are received and complete.

After receipt of all document, acceptable candidates will receive a letter inviting you for an on campus interview. The interview will consist of 2 interviews by 2 separate panels. A campus tour, time for questions, financial aid etc will be available.

The admissions committee will then select the cohort, and a letter will be sent for a position in the cohort. Once the position is accepted, students will be required to pay a $500 place holding fee known as the Confirmation Deposit. The link to pay for this is found online. A program of study will be sent along with all documents for the required background check and drug screen.

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Missouri State School of Anesthesia Agreement/Authorization/Release

By applying for appointment to the Missouri State School of Anesthesia I hereby:

• _{Agree to appear for interviews in accordance with the application process;}

• _{Acknowledge that I have received , or been given access to read, the Rules and Regulations for the} Missouri State School of Anesthesia and confirm that I agree to abide by the same:

• _{Agree to abide by the policies and procedures of the Missouri State School of Anesthesia and the} policies and procedures of Missouri State University and its related facilities;

• Authorize the Missouri State School of Anesthesia and designated representatives to consult with and obtain information from my prior associates, members of Nursing staffs to which I was/am a member, other hospitals, insurance carriers, health plans, HMOs, the National Practitioner Data Bank, the Missouri State Board of Nursing and other state licensing boards and others who may have information bearing on my professional competence, character, health statues, ethics, performance and ability to work cooperatively with others;

• _{Release from liability Missouri State University (including but not limited to the School of} Anesthesia) and all its board members, officers, employees, volunteers, students, agents, and assigns for all actions, statements, and the like associated in anyway with evaluating my application and my credentials and qualifications;

• Release from liability all individuals and entities who provide information to Missouri State

University concerning my application, credentials, qualifications, professional competence, ethics, character and other qualifications of staff appointment and clinical privileges;

• Acknowledge that I, as an applicant for the Masters in Nurse Anesthesia Program have the burden of producing adequate information for a proper evaluation of my professional, ethical and other matters.

• Agree to immediately notify the Missouri State School of Anesthesia of any disciplinary action affecting me (including, without limitation, reprimands or warnings or reduction, probation,

modification, suspension or revocation of privileges) Imposed by any other health care provider and authorize all other health care providers to disclose information to the Missouri State School of Anesthesia or representatives relating to disciplinary action affecting me at such other health care providers;

• Acknowledge that all information submitted by me in this application is true, complete and correct to my best knowledge and belief and that any misstatements in or omissions from this application constitutes cause for denial of appointment or cause for summary dismissal from the Missouri State School of Anesthesia;

• Authorize the Missouri State School of Anesthesia to use photocopies of this release form as original signature.

Date: _Name:

(Please print or type) Signature:

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RN to DNAP Application Checklist:

These materials must be included in your application in order for it to be complete and to be processed for interview consideration. You will not be notified of missing items. It is the applicant’s responsibility to make sure the

application is complete!!! Application deadline is November 1st.

_______ Completed application to the Missouri State School of Anesthesia AND completed

application to MSU Graduate College.

________ Essay on why you are qualified for admission, Nursing history, goals. No more than 250 250 words double spaced.

________ Copy of your certifications (Nursing license, BLS, ACLS, and PALS.) ________ GRE Scores

a. Your official scores will get sent to MSU. (The graduate college school code is R6665). They are an official site for GRE scores.

b. The School of Anesthesia is NOT an official site to send GRE scores. THEREFORE:

It is the applicant’s responsibility to get a copy of your scores along with your application to the School of Anesthesia before the deadline.

_______ Current Resume/Curriculum Vitae

_______ Non-refundable application fee--$50.00

(This must be a check made payable to the Missouri State School of Anesthesia.)

Please note: MSU Graduate School and the School of Anesthesia have 2 separate application fees and 2 separate addresses!!!!!

_______ References: 3 letters of recommendation from non-relative medical professionals,

including your current supervisor. These should be on official letterhead and signed by the professional. They may be sent directly to the School of Anesthesia or FAXed to 417-836-3225.

________ Official transcripts from each institution must be sent to Missouri State School of

Anesthesia AND the Missouri State University Graduate College. Transcripts MUST Include the 5 prerequisite courses: Microbiology, Anatomy, Physiology, Inorganic

AND Organic Chemistry.

_________ Signed Agreement/Authorization form---Please print and sign

_________ Remember: It is your responsibility to make sure everything accompanies your

application. You may follow up on your application with the School of Anesthesia at Missouri State by calling 417-836-5039 to make sure your application is

complete. It is imperative that you send your documents to the correct address!!! ADDRESSES:

Missouri State School of Anesthesia Missouri State University Graduate College Professional 400 ATTN: Graduate College

901 S. National Ave. 901 S. National Ave. Springfield, Mo. 65897 Springfield, Mo. 65897

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OFFICE USE ONLY:

Application

Date application received Application

fee

Agreement/Authorization/Release Form Education

Degree _Date of Graduation

College/University Required Coursework/Transcripts Microbiology Anatomy Physiology Inorganic Chemistry Organic Chemistry References Experience

Total Years of Nursing Total Years of Critical Care Nursing

PACU ICU CCU ER RR Neonatal ICU Neuro ICU Surgical ICU Other Certifications

Current Nursing License

BLS ACLS

PALS

GRE

Date taken

Scores: V Q AW_ Total