MSN Application

* Denotes required field.

• Gender selection is required.

Title*	Mr. Mrs. Ms.
First Name*
Last Name*
Student ID# (if available)
DOB*
Gender*	MaleFemale
Age*	Select One 25 years and younger 26-30 years 31-40 years 41-50 years 51-60 years 61 years and older
Ethnicity*	Select One African American American Indian Filipino Non-Filipino/Asian or Pacific Islander Caucasian Hispanic Other Decline to state
Street Address*
City*
State*	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip*
Home Telephone*
Other Telephone
Email address*
Confirm email address*
Have you applied to the CSUSB MSN Program before?*	Select One Yes, I have No, I have not
If yes, when?
How many other schools/programs are you applying to:
Number of graduate units completed*
Other colleges attended*
Number of upper division units completed*
Current RN license	Yes
By submitting this application, you agree that the above information is complete and accurate.  You have read all the information on this application and understand that proof of ALL prerequisite courses and ANY "additional course" completed and/or in progress will be provided by you before the deadline.
Signature*