College of Nursing

Transcription

College of Nursing
College of Nursing
Student Services Office
985330 Nebraska Medical Center
Omaha, NE 68198-5330
phn: (402) 559-4110
fax: (402) 559-6379
Dear Applicant,
Congratulations on your decision to apply to the University of Nebraska Medical Center, College
of Nursing. The application procedure is a very systematic step-by-step process. The following
information should make the process easier to understand.
1.
The application file on which admission decisions are made consist of:
-
Application Form
Two Letters of Recommendation
High School Transcript
All College Transcripts
Campus Preference Sheet
Application Fee of $45.00 (No fee for those who have previously attended
UNO, UNL, UNMC or UNK)
NOTE: Submit the application form before the supporting material.
Send to:
University of Nebraska Medical Center
Office of Academic Records
Student Life Center
984230 Nebraska Medical Center
Omaha, NE 68198-4230
2:
When your application is received at UNMC Academic Records, they will send you a
letter explaining what is needed to complete your file. It will be your responsibility to
follow-up to ensure that any missing items are received in the Academic Records Office.
3.
When all of the above items for your application are received at UNMC Academic
Records your file will be sent to the College of Nursing for review. You will receive a
letter from your (first Choice) campus Student Services Advisor explaining your status in
the reviewing process.
4.
Application to the College can be made for fall or spring admission. The deadline for
Fall Admission is February 1st and August 1st for Spring Admission. All applications
are processed through the Omaha Division.
5.
You will need to have updated transcripts sent to Academic Records as soon as possible.
Grade reports will work if the institution cannot get the transcript to us by the deadline.
However, before final acceptance an official transcript of all college work is required.
(Over)
6.
When you have been offered a position you will receive a letter of notification. You
should send your letter of acceptance within 10 days. Those not accepting within the
specified time period will lose their position.
7.
Upon receipt of the acceptance letter you will receive information from the UNMC
Financial Aid Office. It is essential that you respond immediately to the Financial Aid
Office if you wish to be eligible for financial aid and/or scholarships.
8.
You will be notified by your campus Student Services Advisor about your status in the
admission process.
9.
The following are the Student Services Advisors for each division of the College of
Nursing:
Michele Saucier
(402) 472-7343
Lincoln Division
1230 O Street, Suite 131/ P.O. Box 880220
Lincoln NE 68588-0220
Larry Hewitt
(402) 559-5102
Omaha Division
985330 Nebraska Medical Center
Omaha NE 68198-5330
Hilary Christo
(308) 865-8322
Kearney Division
1917 West 24th Street
Kearney NE 68849-4510
Karen Schledewitz
(308) 632-0413
Scottsbluff Division
Panhandle Research and Extension Division
4502 Avenue I
Scottsbluff NE 69361-4939
Or you may dial toll-free:
1-800-626-8431 Ext. 4110
Thank you,
UNMC College of Nursing
Admissions Committee
LPH/lph
Revised 1/09
________________________________________________________
NAME (Please Print)
OFFICE OF ACADEMIC RECORDS
THE UNIVERSITY OF NEBRASKA MEDICAL CENTER
984230 Nebraska Medical Center, Omaha, NE 68198-4230
APPLICATION FOR ADMISSION
1.
Please check program for which application is made:
Deadline for All
Program
Application Material
Begins
November 1
end of May
November 1
end of August
(Check applicable program box)
Radiography
Nuclear Medicine Technology
January 15
January 15
end of August
end of August
For those applicants who have completed required college courses plus
an accredited radiography or nuclear medicine technology program by the
enrollment date and are nationally certified or candidates for certification:
Nuclear Medicine Technology
Radiation Therapy Technology
Diagnostic Medical Sonography
Radiography — CT / MRI
Radiography — CVIT
January
January
January
January
January
end
end
end
end
end
School of Allied Health Professions Programs
Division of Clinical Laboratory Science — B.S. (combined program
of UNMC at NHS Hospital & Clinic and Nebraska Methodist
Hospital)
Division of Physical Therapy Education — D.P.T.
Division of Radiation Science Technology Education — B.S.
Division of Clinical Perfusion Education — M.P.S.
Division of Medical Nutrition Education — Certificate
15
15
15
15
15
of
of
of
of
of
August
August
August
August
August
January 1
end of August
February 15
mid August
March 1
end of August
(for applicants who have completed an accredited baccalaureate program in
dietetics by the enrollment date)
Division of Cytotechnology — Certificate
College of Nursing Programs (Recommend early application)
Nursing — B.S.N. for all Divisions
FALL Term
February 1
SPRING Term
August 1
For applicants who have a Bachelor’s degree from an accredited institution
Accelerated BSN- Lincoln Campus Only
May 15
Accelerated BSN- Omaha Campus Only
May 15
Accelerated BSN- Scottsbluff Campus Only
May 15
end of August
January
January
January
January
College of Pharmacy
Doctor of Pharmacy — Pharm.D.
January 1
end of August
2.
HAVE YOU APPLIED PREVIOUSLY TO UNMC? YES
NO
If Yes, indicate: Year(s)___________ Program(s) ________________
When do you expect to enroll? ________
_______ Note:You will be considered for only the immediate next class and must reapply if
month
year
not accepted.
3.
FEE: If you have previously attended UNO, UNL, UNK, or UNMC campus, DO NOT submit a fee with this application. If you have never been enrolled
at any of the University of Nebraska system campuses, enclose a check or money order for $45.00 payable to UNMC. The fee is non-refundable and
not applicable toward tuition. This fee is subject to change upon review by the Board of Regents.
4.
TRANSCRIPTS: Applicants must request official transcripts from each institution previously attended, regardless of credit earned. Transcripts must be
sent from the Registrar to the UNMC Office of Academic Records. If you are applying to multiple UNMC programs, official transcripts must be submitted
for each program application.
High school transcripts are required from applicants to the College of Nursing, Division of Clinical Laboratory Sciences, and Division of Radiation
Science Technology.
5.
CHANGE OF CAMPUS FORM: Applicants from UNO, UNK and UNL can request a "Change of Campus" form from their current campus Registrar.
Request the Change of Campus be sent directly to the UNMC Office of Academic Records. If applying to Medical Nutrition Education, send official
transcripts and all application material directly to the Program Director.
6.
REFERENCES: Applicants are to distribute the enclosed forms with stamped envelopes to the referent for completion and return directly to the address
on the form. Three (3) references are required except for Nursing (two references). References should not be submitted from relatives.
Cytotechnology references letters need to be sent directly to Program Director.
7.
PHOTOGRAPH: Required from applicants to College of Pharmacy. Attach one billfold size recent photograph with date taken and your signature written
on the back.
8.
Mail completed application and fee (if required) to the UNMC Office of Academic Records. All materials submitted in support of your application become
the property of the University and cannot be returned or forwarded.
Medical Nutrition Education applications and fee (if required) should be sent to the Program Director for nationwide computer match
processing.
9.
Scholarship and Financial Aid applications will be mailed to applicants accepted for admission.
SSD-40 (Rev. 11//08)
2
UNMC APPLICATION FOR ADMISSION
Please Type or Print in Ink
______ Female ______ Male
SOCIAL SECURITY #
Name _____________________________________________________________________________
Last
First
Middle
Former
Name(s) __________________________
(if any appear on records)
Current Address ________________________________________________________________________________________________________
Street
City
County
State
ZIP Code
Permanent Address _____________________________________________________________________________________________________
Street
City
County
State
ZIP Code
Current Phone _________ ________________
area code
local
Birthdate ______/______/______
____ Parent(s)
Work Phone _________ ________________
area code
local
Birthplace ________________________________________
City/State
____ Guardian(s)
Permanent Phone ______ ____________
area code
local
Hometown ___________________________
City/State
Name _____________________________________________________________________________
Last
First
Middle
Address of Parent or Guardian ____________________________________________________________________________________________
Street
City
County
State
ZIP Code
Person most helpful in my selection of a UNMC educational program:
____ High School Counselor
____ College Advisor
____ UNMC Faculty/Staff
Your e-mail address: _____________________
____ Other _______________________________
NON-U.S. CITIZENS — Please complete the following:
Country of Citizenship __________________________________
Last Visa Classification _______________________________________
Arrival Date in U.S. _____________________________________
Permanent Residents, please list Alien Card number (Form I-151) __
*UNITED STATES CITIZEN: PREDOMINANT ETHNIC BACKGROUND
_____ CAUCASIAN
_____ ASIAN OR PACIFIC ISLANDER. Check Subcatetgory (A person of ____ Chinese, ____ Filipino, ____ Hawaiian, ____ Korean, ____ Vietnamese,
____ Japanese, ____ Indian or Pakistani, ____ Other Pacific Islander or Asian.)
_____ BLACK. Not of Hispanic Origin (A person having origins in any of the Black Racial Groups.)
_____ HISPANIC. Check Subcategory (A person of ____ Mexican, ____ Puerto Rican, ____ Cuban, ____ Central or South American or other Spanish
Culture or Origin, regardless of race.)
_____ AMERICAN INDIAN or ____ ALASKAN NATIVE. Check appropriate category. (A person having origin in any of the original peoples of North
America.)
*Supplying this information is optional with the applicant and is not a requirement for admission. The data is used by the U.S. Departments of Health ahd Human
Services and Education for statistical purposes.
These questions are related to residency and are to be completed by: a. Each applicant over 18 years of age OR
b. Parent/guardian of applicant less than 19 years
Midwest Student Exchange Program (MSEP) status is desired if admitted Yes
No
(Open to residents in the states of Kansas, Michigan, Minnesota, Missouri, and North Dakota)
Do you claim to be a resident of Nebraska?
Yes
No
If Yes, Nebraska County of Legal Residence ________________________________
If Yes, date you began living in Nebraska ___________________________________
Month
Day
Year
If No, state of legal residence ______________________________________________
Do you have a Nebraska driver/s license?
Yes
No
Are you registered to vote in Nebraska?
Yes
No
If employed, have you filed a Nebraska income tax return? Yes
No
Note: You may be required to verify your Nebraska residency by filing an application with the UNMC Office of Academic Records and showing
proof of above items.
SSD-40 (Rev. 07/08)
3
Give chronological record of previous part-time or full-time employment:
Name of Employer
Address
Type of Position Held
Inclusive Dates
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
NAME ALL EDUCATIONAL INSTITUTIONS ATTENDED
List in chronological order the ALL colleges, universities, professional, technical or business schools you currently attend or have attended (even if no
credit has been earned) on either correspondence, evening or daytime schedules. Begin with high school and date of graduation.
High School _____________________________________
Location _________________________________________________________
City
State
County
Date Graduated: ___________________________________________________
Month
Year
College, University,
Professional, Technical
or Business Schools
Attended
Dates
City
State or County
Entered
Left
Mo. Yr. Mo. Yr.
No. of
Hours
Earned
Cumulative
Grade Point
Average
(college only)
Program
Degree or Certificate
Received or Expected
Date
Received
or Expected
Mo. Yr.
If your education has been interrupted, list in detail your activities during the intervening period. Also, indicate if you have been suspended
or dismissed from a collegiate institution.
WORK IN PROGRESS
Instructions:Please list all courses currently in progress and those which you plan to complete prior to your enrollment at University of Nebraska
Medical Center.
1. CURRENT
2. FUTURE
Fall
Fall
Winter
Winter
Spring
Semester
Quarter Year__________
Spring
Semester
Quarter
Year__________
Summer
Summer
Name of Institution: ___________________________________
Name of Institution: _____________________________________
Dept. Name
SSD-40 (Rev.07/08)
Name of Course
Credit Hrs.
Dept. Name
Name of Course
Credit Hrs.
4
List extra-curricular interests and give number of years of participation
in each.
List honors, awards (i.e., scholarships, etc.). Specify high school (HS)
or college (C).
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
________________________________________________________
Please provide a narrative describing your interest in the selected area of study, particularly stressing your professional career goals. Radiation Science
applicants need to submit separate narratives for each program. Clinical Perfusion applicants need to provide typed (double-spaced) narrative on separate
sheet. Pharmacy applicants should complete the Personal Questionnaire and one page essay in place of this narrative.
NOTE: Should you desire to arrange for a disability accommodation in conjunction with completing the application process, please contact Ms. Ronda
Stevens, Coordinator, Counseling and Student Development Center, at the address on the front of this application. Her phone is (402) 559-5553.
FOR ALL APPLICANTS:
One of the objectives of the University of Nebraska Medical Center is to recruit and retain persons of high moral and ethical character. In accordance with
this objective, the University of Nebraska Medical Center reserves the right to review a candidate’s suitability for admission.
I certify that information on this application is complete, accurate and true; and I understand that any information given falsely or withheld may make me
ineligible for admission and/or enrollment. I agree to abide by the policies and regulations of the University of Nebraska Medical Center. I will inform the
UNMC Office of Academic Records of any change in my plans to attend.
_________________________________________________________
Month
Day
Year
_________________________________________________________
APPLICANT’S SIGNATURE
Admission to the University of Nebraska Medical Center shall not be denied to any person because of age, sex, race, color, national origin, religion, political
beliefs, or disability (as defined in The Rehabilitation Act of 1973).
SSD-40 (Rev. 07/08)
University of Nebraska Medical Center
College of Nursing
Campus Preference Sheet
Name
SSN
List below the College/University you have completed or working on your Pre-Nursing Admission Courses:
A.
FIRST CHOICE: Please indicate the campus you would like to attend below:
CHOOSE ONLY ONE
PLEASE PRINT CLEARLY:
•
•
•
•
Omaha Division
Lincoln Division
Scottsbluff Division
Kearney Division
B.
CAMPUS PREFERENCE: The College of Nursing is administered by the University of Nebraska Medical
Center in Omaha with the nursing program being offered at four locations; in Omaha (on the UNMC campus), in
Lincoln (on the UNL Campus), the West Nebraska Division (in Scottsbluff) and in Kearney (on the UNK Campus).
PLEASE NOTE: If you indicate that you will attend a campus (even if it might not be your first choice), you will be
expected to enroll at that campus if offered a position. Also, you do not need to list more than one campus unless
you have an interest in attending more than one of the available campus choices. Please list all campuses you wish
to be considered for. Listing more than one campus only increases your chances of being placed at one of the four
campuses; it doesn’t increase your chances of being placed on your first choice campus.
C.
REGISTERED NURSES with a current license wishing to complete the BSN program should make a
campus selection to complete the clinical component of Community Health and the Lab component of Health
Assessment. Your campus selection should be a choice which is convenient to travel to at least once a week.
PLEASE PRINT CLEARLY (Remember; second, third and/or fourth choices are NOT required)
• Omaha Division
• Lincoln Division
• Scottsbluff Division
• Kearney Division
PLEASE PRINT CLEARLY:
SECOND CHOICE
THIRD CHOICE
FOURTH CHOICE
D.
If we cannot offer you admission to your first or second choice campus you will be placed on your first
choice alternate list, if you are qualified.
I affirm that the above statements are true and fully intend to abide with the commitments.
Signature
Return this form with your Application to:
Date
Office of Academic Records
University of Nebraska Medical Center
984230 Nebraska Medical Center
Omaha, NE 68198-4230
Revised: 8/06
College of Nursing
Letter of Recommendation
Applicant Instructions: Two references are required to complete your application. We recommend you
consider requesting references from individuals who know you well and can comment on your suitability
and preparation for a health care career and/or your academic preparation.
Name of Applicant:
(Please Print)
(Last)
(First)
(Middle)
(Maiden)
RELEASE: Under the Family Education Rights and Privacy Act, enrolled students have the right to
inspect their files upon request. In order to inform the person you have requested to write a letter of
recommendation whether the letter will be held in confidence or if the letter will be open to your
inspection, please check [¥] one of the following statements. Waiving your rights to see this letter of
recommendation is not a requirement for admission.
[ ] I hereby do waive my rights to access this letter of recommendation.
or
[ ] I hereby do not waive my rights to access this letter of recommendation.
____________
(Date)
___________________________
(Applicant’s Signature)
______--_____--______
Soc. Security Number
===============================================================
1. In what capacity have you been associated with this student? Please check one or more of the
following choices:
[ ] Instructing Lecture or Laboratory ____________________ (specify courses)
[ ] Academic Advising
[ ] Other _________________________________ (specify)
2. How long have you known the applicant?
3. How well do you know the applicant? [ ] Very well [ ] Somewhat [ ] Not very well
4. What major strengths do you believe this applicant exhibits?
5. What weaknesses or issues might interfere with this applicant’s success in college course
work?
6. What experiences has this candidate had that you believe would serve them well as a professional
nursing student?
7. Do you have any additional comments relevant to the applicant’s suitability to the nursing profession?
8. How would you rank this student in the following categories relative to other nursing students or
nursing professionals you know?:
Characteristics
Top
10%
Top
25%
Average
Below
25%
Below
10%
No basis to judge
Intellectual Curiosity: their
pursuit of available resources
inside/outside the classroom.
Self-Reliance: Sense of
responsibility: dependability:
promptness:
conscientiousness: selfconfidence.
Maturity: Personal
development: ability to cope
with life situations: awareness
of own strengths and
weaknesses: self-confidence.
Judgment: Ability to analyze a
problem: common sense:
decisiveness.
Interpersonal Interactions:
rapport: cheerfulness: tact:
cooperation: empathy.
Commitment/Motivation:
genuineness: depth of
commitment: goals set for
themselves: reason for
choosing nursing as a career.
9.
Based on the information that you have provided throughout this recommendation, how comfortable
would you be with this student being your nurse or taking care of a loved one?:
[ ] Very Comfortable
[ ] Somewhat Comfortable
[ ] Somewhat Uncomfortable
[ ] Very Uncomfortable
[ ] Don’t Know
10. Personal references are a valued and an integral part of the admissions process. Our nursing
program seeks individuals who have the potential for success in a rigorous educational program and
possess the personal attributes required to become a competent and compassionate health care
provider. If would like to provide some additional insight on this student, please attach an additional
narrative statement on professional letterhead and provide comments about the student’s developing
maturity, problem-solving ability, originality, unique skills, cultural sensitivity, attributes, or future
potential. Your candid evaluation of the applicant will be of significant value and is appreciated.
(Please type or print)
(Printed Name)
(Date)
(Signature)
(Mailing Address)
(Phone)
(Institution/Company)
(Position)
================================================================
Return to:
University of Nebraska Medical Center, Office of Academic Records
Student Life Center, 984230 Nebraska Medical Center
Omaha, NE 68198-4230
College of Nursing
Letter of Recommendation
Applicant Instructions: Two references are required to complete your application. We recommend you
consider requesting references from individuals who know you well and can comment on your suitability
and preparation for a health care career and/or your academic preparation.
Name of Applicant:
(Please Print)
(Last)
(First)
(Middle)
(Maiden)
RELEASE: Under the Family Education Rights and Privacy Act, enrolled students have the right to
inspect their files upon request. In order to inform the person you have requested to write a letter of
recommendation whether the letter will be held in confidence or if the letter will be open to your
inspection, please check [¥] one of the following statements. Waiving your rights to see this letter of
recommendation is not a requirement for admission.
[ ] I hereby do waive my rights to access this letter of recommendation.
or
[ ] I hereby do not waive my rights to access this letter of recommendation.
____________
(Date)
___________________________
(Applicant’s Signature)
______--_____--______
Soc. Security Number
===============================================================
1. In what capacity have you been associated with this student? Please check one or more of the
following choices:
[ ] Instructing Lecture or Laboratory ____________________ (specify courses)
[ ] Academic Advising
[ ] Other _________________________________ (specify)
2. How long have you known the applicant?
3. How well do you know the applicant? [ ] Very well [ ] Somewhat [ ] Not very well
4. What major strengths do you believe this applicant exhibits?
5. What weaknesses or issues might interfere with this applicant’s success in college course
work?
6. What experiences has this candidate had that you believe would serve them well as a professional
nursing student?
7. Do you have any additional comments relevant to the applicant’s suitability to the nursing profession?
8. How would you rank this student in the following categories relative to other nursing students or
nursing professionals you know?:
Characteristics
Top
10%
Top
25%
Average
Below
25%
Below
10%
No basis to judge
Intellectual Curiosity: their
pursuit of available resources
inside/outside the classroom.
Self-Reliance: Sense of
responsibility: dependability:
promptness:
conscientiousness: selfconfidence.
Maturity: Personal
development: ability to cope
with life situations: awareness
of own strengths and
weaknesses: self-confidence.
Judgment: Ability to analyze a
problem: common sense:
decisiveness.
Interpersonal Interactions:
rapport: cheerfulness: tact:
cooperation: empathy.
Commitment/Motivation:
genuineness: depth of
commitment: goals set for
themselves: reason for
choosing nursing as a career.
9.
Based on the information that you have provided throughout this recommendation, how comfortable
would you be with this student being your nurse or taking care of a loved one?:
[ ] Very Comfortable
[ ] Somewhat Comfortable
[ ] Somewhat Uncomfortable
[ ] Very Uncomfortable
[ ] Don’t Know
10. Personal references are a valued and an integral part of the admissions process. Our nursing
program seeks individuals who have the potential for success in a rigorous educational program and
possess the personal attributes required to become a competent and compassionate health care
provider. If would like to provide some additional insight on this student, please attach an additional
narrative statement on professional letterhead and provide comments about the student’s developing
maturity, problem-solving ability, originality, unique skills, cultural sensitivity, attributes, or future
potential. Your candid evaluation of the applicant will be of significant value and is appreciated.
(Please type or print)
(Printed Name)
(Date)
(Signature)
(Mailing Address)
(Phone)
(Institution/Company)
(Position)
================================================================
Return to:
University of Nebraska Medical Center, Office of Academic Records
Student Life Center, 984230 Nebraska Medical Center
Omaha, NE 68198-4230
UNIVERSITY OF NEBRASKA MEDICAL CENTER
DISCLOSURE STATEMENT
Completion of this form is a formal part of the application process. This form must be completed and submitted before any
offer of admission can be made. A positive response to any of the questions below will not necessarily result in denial of
admission. Information on this form will be available ONLY to the Associate Dean or his/her designee for evaluation of your
suitability for full admission. This information will be held CONFIDENTIAL.
Which College of Nursing campus is listed as number (1) on your campus preference?
Omaha
Lincoln
Kearney
Scottsbluff
1. Have you ever had a health care license canceled, limited, suspended, revoked or denied for any reason?
YES NO
2. Have you ever been subject to proceedings by a licensing agency to cancel, limit, suspend or revoke
a license for any reason?
3. Have you ever been convicted of any criminal offense (including misdemeanors and felonies) other
than a minor traffic violation or been the defendant in a civil suit?
4. Are you currently using alcohol or a controlled substance(s) that would affect your ability to participate
in, or prevent you from successfully completing, an academic program in a reasonable period of time?
(Please be aware that you may be subject to a drug screen before some agencies will allow
clinical experiences.)
5. Have you ever had any substantiated referrals for child or adult maltreatment that would be on file
with the Nebraska Child or Adult Abuse/Neglect registry? (You may be required to give authorization
For a release of information for this registry.)
6. Have you been issued a dishonorable discharge from the US Military ?
YES NO
YES NO
YES NO
YES NO
YES NO
*FOR ANY YES RESPONSES TO THE ABOVE QUESTIONS, APPEND DETAILS ON A SEPARATE SHEET(S)
In evaluating conviction records, the University of Nebraska Medical Center considers the following factors:
1. The relative relationship of the conviction to the program to which you are being considered for admission
2. Circumstances surrounding the conviction
3. The time interval from the conviction to submission of an application for admission.
4. Other relevant history
5. Degree of rehabilitation
Read this statement carefully: I certify that the information contained in this University of Nebraska Medical Center College
of Nursing disclosure is true to the best of my knowledge and belief. Because of the high ethical and professional standards to
which nurses are held, the failure to provide pertinent information regarding an act or event, such as the ones outlined in this
document, may result in revocation of my admission, or if admitted, dismissal from the College of Nursing, regardless of when
discovered. I agree to promptly inform the College of Nursing of any changes in any matters covered herein, even if such
changes occur after I have submitted my application or enrolled as a student. I grant permission to the University of Nebraska
Medical Center College of Nursing to investigate my employment record, educational record, criminal record, and other
records to verify the information I have provided throughout the application process and any additional information I have
provided and release the University from any liability resulting from such investigation.
If you understand the statement printed above, please complete the information below:
_________________________________________
Print Your Name
______________________
Date
_________________________________________
Signature
_______________________
Social Security Number
Mail this form in a separate envelope to:
UNMC Academic Records - Attn: Crystal
984230 Nebraska Medical Center
Omaha, NE 68198-4230