@ Cramele § SACRAMENTO STATE Official Transcript Request Form EAM Office of the University Registrar MAIL REQUEST OR SUBMIT IN PERSON TO: Outgoing Transcripts, 6000 J Street, Sacramento, CA 95819-6056 ‘00 per transeript ‘8 per transcript + PLUS S18 Mat fee Tesh wansript~ $23 2 Rash taneript~ S31 3 Rush wansergt= $39 AllRecords $15.00 per ss Unoflicil photocopied tansrps which Sa State aso file fom othr schoo nclides an uncial ccpy of Se Ste azn tnscrpt (FOR PERSONAL. USE ONLY) ‘Your request wil be returned to you and not processed i Thre is ald on your td = al payee vcd «Wing ple» Fo incomplete Name__Doe Jane Student ID #/SSN_123-45-6789__ Former Name(s) Jane Smith, Jane Jones. JD Smith site_CA ___7ip_95678 _Emailjane.doe@gmailicom __ ‘Address 1234 Anywhere Street City Sacramento Phone _ (916) 555-5555 __AltPhone (916) 333-3333. Date of Birth 09/28/1989 eeeeeeee EE ‘Are you currently enrolled? (Circle One) No Last Semester/Year of attendance at Sac Stat SPRING 2015 Term of Gradua REASON FOR TRANSCRIPT RI IT (Please check all that Student Transfer (D Scholarship D. Military (Grad Schoo! / Professional School 0 Employment BB Personal/Other would like to pick-up my transcripts “UNDABLE (} Hold for current grades (Semester/Year) 1 Official $16.00 1) Hold for degree posting SPRING “15 _(Semester/Year) Rush my order for an additional $15.00 fee Hold for grade change from to _Course/Year_ a set of All Records at $15.00 cach Total fees included: Other special instructions (3) to the following address(s): Please print additional addresses om a separate sheet of paper and attach to this form, 1” cde orm wih rs ‘ele fom wi rp tote of Cope: Sondra Lee Tane Doe School of Nursing 1234 Anywhere Steet 6096 | Sacramento, CA 95678 STUDENT SIGNATURE (REQUIRED) OFFICE USE ONLY: Holds Clesed Sse State Ropes s AM Requests __$_ Rush Service $_ Grand Tou sevens (Chock Went _ Red Datei 1 Dae Veriiedtnitals_/_Date Seni. /Example) NOTIFICATION OF INTENT TO TAKE THE NCLEX-RN EXAM This form must be completed and submitted to the School of Nursing in order to take the NCLEX-RN exam and be eligible for an Interim Permit Please Print Clearly or Type ‘Name: (Last, First, Middle) Maiden Name: Previous Name(s): Doe, Jane Doris ‘Smith Jane Jones, JD Smith Date of Birth: ‘SSN: 103-45-6789 School of Nursing: : : : California State University, Mo: 09 Day: 28 Yr: 1989 ce EY lintend to take the NCLEX-RN Exam as a: Graduate of the Bachelor of Science-Nursing Program (Please check this box if this will be your FIRST Bachelor's Degree) OC Non-Graduate (completed all nursing requirements but still need to complete G.E. Requirements) C_LVN 30-Unit Option (| am a licensed LVN and will have completed 30 RN units). | anticipate completing 30 RN units on: Please complete the following if you already hold a Bachelor’s Degree CJ Graduate of a previous Bachelor Degree Program. This box is for SECOND BACHELOR STUDENTS ONLY. Please list your latest degree, when it was earned and from where. Latest Degree Held: Earned (date): From (school) Signature of Applicant: Gone 2l2re Date: March 25, 2015 C Email address:___jane.doe@gmail.comee | oS Examples @ Sencrwenrercorsunss~"S@ | BOARD OF REGISTERED NURSING PO Box 944210, Sacramento, CA 94244-2100 (016) 322-3350 F (916) 574-8637 | www.mn.ca.gov Louise R. Bailoy, MEd, RN, Executive Officer INDIVIDUAL CANDIDATE WORKSHEET (1) - NONSCSUSICOURSES'ONLY, (MUST.BE ONE PAGE ONLY — TYPED) NURSING PROGRAM: California State University, Sacramento NAME: (Last, Date of Birth: 09/28/1988 oid any processing delays, please provide tho complote name of tho course. For example, if Anatomy is included in Bio 5, please indicate that Bio 5 is Anatomy. Caner TRLEDESCIeTON | wears [SoerLenO OAT TE SSTTTTON ENGL 1A Eralsh 8 | summar2008 Aerian Fiver Cooge Spe sot Oa A ra 2008 Aericn River Caoge Phil 4 — Critical Thinking A ‘Spring 2009 ‘Sacramento City College q Stas 200-latotesiaiscs [A | Spng on0 sacrament i Clege hem 5 heist 8 | Sang 2000 Secramato ity Cotege Bio 25—Human anatomy A Fan 2009 Sacamento Gy Colege Bio 26—HumanPhysnooy [A Fal 2009 Socrameno iy Cooge Bi 40 —Misoiloay A at 2009 Sacramento Cy Cage Teeriy under panaliy of parjury undar the laws ofthe State of California thatthe Yoragolng ie Wie and correct Thn't Slan Here — om: ‘Signature of Nursing Director: (Rev. 8/2013)Exom ple INDIVIDUAL CANDIDATE WORKSHEET (2) (MUST BE ONE PAGE ONLY - TYPED) WURSING PROGRAM: California State University, Sacramento NAME: (Lat, First, Mila) Dato of Bit O9RETD Doe, Jane Doris To avoid any processing delays, please provi ete complete name of the course. For example, if Anatomy is included in Bio 5, please indicate that Bio 5 is Anatomy. ‘COURSE TITLEIDESCRIPTION | GRADE | COMPLETION DATE NAME OF INSTITUTION Psyc 300 — Intro to A Spring 2010 csus Psychology 2 . Chdv 30 ~ Human Lifespan A Spring 2010 csus Development i Nutri 300 - Nutrition 8 ‘Spring 2010 csus Soc 1 - Intro to Sociology A Fall 2010 csuS xs 14- Phistmacctoay, A Fall 2010 csus csus csus : csus | csus csus i ; csus csus a | : csus en csus csus csus : - csus csusExamp) CA 9 | somnoor nccisreneo nurse & tnntnennumnns | POBOx 944210, Sacramento, CA 94244-2100 P (016) 322-3350 F (916) 574-8637 | wwnw.mn.ca.qov, Louise R. Bailey, MEd, RN, Executive Officer REQUEST FOR TRANSCRIPTS “TO APPLICANT: Send this form to your basic schools) of nursing, If you need to contact mare than one schodl this form may be reproduced, “Transcripts are required from each sthool where nursing requirements or general education courses were completed. Transcripts must include all competed coursework, cinical practice of traning and reflect the degree awarded. Your school may require a processing fee. {A._TO BE COMPLETED BY APPLICANT] TAST NAME: Doe FIRST NAME: Jano MIDDLE NAME: Doris | ADDRESS: 1234 Anywhere Strect. ATE OF BIRTH: O9/2877969——| ae re ‘State [ Country | PostalZip Code | SOCIAL SECURITY NUMBER: Sacramento ca | USA 95678 123-48.6789| | PREVIOUS NAMES: nclding Uaiden) Jane Smith, Jane Jones, JD Smith NAME OF PROFESSIONAL REGISTERED NURSING SCHOOL: YEARS ATTENDED: 2010-2015 California State University, Sacramento ae ‘State | Country | PostallZip Code | YEAR GRADUATED: 2015 cA USA 95819 Tee |, SIGNATURE OF APPLICANT, DATE:_3/25/15 B._TO BE COMPLETED BY THE OFFICE OF THE SCHOOL OFFICIAL RELEASING TRANSCRIPTS| ‘The above applicant has applied for a license to practice as a registered nurse in California. Please provide the following information and attach a complete official transcript. Please mail to the Board of Registered Nursing at the above address. 'DO NOT SIGN OR SUBMIT THIS FORM PRIOR TO COMPLETION DATE OF THE REGISTERED NURSING PROGRAM. ENTRANCE DATE: | DATE DIPLOMA/ DEGREE AWARDED: | DATE NURSING REQUIREMENTS COMPLETED: If degree received prior to entering nursing program, list name of school and type of degree: NAME OF SCHOOL: California State University, Sacramento | TYPE OF DEGREE: SIGNATURE OF SCHOOL OFFICIAL: TE TITLE: _ASC I