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University of Saskatchewan College of Nursing Supplementary Application for Admission to the Master of Nursing Program Application Deadline November 15 2007 for Thesis and Course-Based February 15 2008 for Advanced Nurse Practitioner We would appreciate the following information to supplement your application. Please complete all sections of this form. Thank you for your assistance. Name Phone day Address Phone evening Postal Code E-mail address Active Current Nursing Registration Associate Please enclose a Xerox copy of your current registration Province of Registration Attendance full time part time Program Option Course-based Education/Leadership Advanced Nurse Practitioner Thesis If thesis what area would you study Note College priorities are rural aboriginal mental health forensic nursing education interprofessional education* Do you have a faculty supervisor in mind Have you contacted this person Yes No Is your participation/registration dependent on funding Yes No If distance delivery was an option would you prefer this Yes No If courses were available in another Saskatchewan city e*g* Regina or Prince Albert would you prefer this Yes No Publications list Conference Presentations list Research Assistant Positions describe to whom etc* Leadership in Nursing Organizations e*g* institutional committees SRNA SUN etc* Clinical Specialty Certification describe Please include a personal letter in which you identify your goals and objectives for this degree and how it will help you in your future career goals. Please ensure the College of Nursing receives original copies of your transcripts from all post-secondary institutions attended* Date Revised September 2007 Signature. Name Phone day Address Phone evening Postal Code E-mail address Active Current Nursing Registration Associate Please enclose a Xerox copy of your current registration Province of Registration Attendance full time part time Program Option Course-based Education/Leadership Advanced Nurse Practitioner Thesis If thesis what area would you study Note College priorities are rural aboriginal mental health forensic nursing education interprofessional education* Do you have a faculty supervisor in mind Have you contacted this person Yes No Is your participation/registration dependent on funding Yes No If distance delivery was an option would you prefer this Yes No If courses were available in another Saskatchewan city e*g* Regina or Prince Albert would you prefer this Yes No Publications list Conference Presentations list Research Assistant Positions describe to whom etc* Leadership in Nursing Organizations e*g* institutional committees SRNA SUN etc* Clinical Specialty Certification describe Please include a personal letter in which you identify your goals and objectives for this degree and how it will help you in your future career goals. Please ensure the College of Nursing receives original copies of your transcripts from all post-secondary institutions attended* Date Revised September 2007 Signature.

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