Texas A&M International University

A Member of the Texas A&M University System

College of Nursing and Health Sciences
Dr. F. M. Canseco School of Nursing

Application for Clinical Nursing Courses

Name: ____________________________________________________________________________________
Last First Middle

TAMIU Student ID: ___________________________________________ DOB: ________________________

Physical Address: ___________________________________________________________________________

Street City State Zip Code

(If different from physical address)

Mailing
Address: __________________________________________________________________________________
Street City State Zip Code

Cell Phone: __________________________________ Other Phone: _______________________________

TAMIU Student Email Address: ________________________________________________________________

Personal Email Address: _____________________________________________________________________

In Case of Emergency Notify: __________________________________________________________________

Name Phone Number Relationship

Licensure Verification

If you are a Licensed Vocational Nurse (LVN) or a Registered Nurse (RN), please provide the information below.
State: __________ License Number: __________________________ Expiration Date: ___________________

Are you an EMT-B? Yes No or Are you an EMT-P? Yes No

Are you an Allied Health professional (e.g. Respiratory Tech, Occupational/Physical Therapist, Phlebotomist, etc.)?

Yes No Other: _____________________________________________________________________

Verification and Signature

I certify that the information on this application is complete and correct.

__________________________________________________________ ____________________________
Signature Date