Student Nurse Residency Program Application Application InformationName(Required) First Middle Initial Last Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone(Required)Email(Required) Education InformationProgram Attending(Required) Name of College(Required) Address(Required) City State / Province / Region ZIP / Postal Code Degree Pursuing(Required) Graduation Date(Required) MM slash DD slash YYYY GPA(Required)Please enter a number from 0 to 6.Other Colleges Attended?(Required) Yes No Other Colleges AttendedDegree PursuingMajor/DegreeGraduation DateGPAStudent ID Add RemoveI will begin my 3rd semester of the nursing program on:(Required) MM slash DD slash YYYY Have you ever been employed by or volunteered at RMC?(Required) Yes No If so, What Department?(Required) Date From(Required) MM slash DD slash YYYY Date To(Required) MM slash DD slash YYYY Have you ever been convicted of a law violation?(Required) Yes No Are you a relative of anyone working at RMC?(Required) Yes No Relative's Name(Required) First Last Relationship(Required) Department(Required) Work ExperienceEmployer Name:(Required) Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Job Title:(Required) Supervisor Name:(Required) First Last Phone(Required)Dates of Employment Date From(Required) MM slash DD slash YYYY Date To(Required) MM slash DD slash YYYY Why I believe I should be selected to the Nurse Residency Program:(Required)Consent(Required) By selecting the box, I have read and agree to the following consent:Consent for Release of Information “I hereby consent to the release of any information in connection with the foregoing that in the sole judgment of the Northeast Alabama Regional Medical Center (RMC) may be of assistance in evaluating my scholarship application. I hereby waive any confidentiality with respect to such information insofar as the Northeast Alabama Regional Medical Center (RMC) is concerned, since it is my understanding that the information will be used solely for the evaluation of my application for scholarship and for no other purpose.”Duties:(Required)Transcript(Required)Max. file size: 25 MB.Please upload your transcript hereLetters of Recommendation(Required) Drop files here or Select files Max. file size: 25 MB, Max. files: 3. Please upload three letters of recommendation (professional and academic references recommended) Δ
