ICMSN : Nursing Consortium

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First Name
Last Name
Address Line 1
Address Line 2
City
State
Zip Code
(5 digit code, use only numbers)
Phone
(XXX-XXX-XXXX format)
Email Address
(Southeastern students must use email as your WNumber@selu.edu)
Confirm Email Address

Date of Birth
(MM/DD/YYYY format)
Home School
WNumber
(Required for only Southeastern students in the format W1234567)
Year of High School Graduation
Expected University Graduation Date
(MM/DD/YYYY format)
Track
Are you fulltime or parttime student?
Ethnicity
Race
Gender