IEN Application

Dominican University of California

Application for Admission: Internationally Educated Nurses Program

First Name

Last Name

Birthdate

Phone Number:

Email:

Country

Street

City

Region

Postal Code

Course(s) Needed per Your CA BRN Deficiency Letter:

Name of the licensing analyst listed at the end of your CA BRN deficiency letter

Entity number listed at the top of your CA BRN deficiency letter

Country of Degree/License

Nursing Program Graduation Year:

Do you have a SSN or Tax ID, such as an ITIN? It is required.

SSN

Tax ID

Do you hold an RN license outside of the U.S.?

Yes

No

Are you a licensed RN in the U.S.?

Yes

No

Are you a licensed LVN in the U.S.?

Yes

No

Are you currently employed in a patient care setting?

Yes

No

If employed in a patient care setting, please provide:

Agency:

Position:

I understand that it is my responsibility to thoroughly read and understand the requirements stated in my letter from the BRN and answer the above questions honestly. Dominican is not responsible for analyzing or interpreting the contents of the letter.

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