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Office of Continuing Education:
Legal Nurse Consultant Program


Registration is now open for the Spring 2015 Legal Nurse Consultant Program being held in the Cleveland area.

Spring 2015

Application for
The Ohio State University at Lima
Legal Nurse Consultant Program


Lastname: Firstname: Middle Name:

Address: City: State: Zip:

Date of Birth: // Home Telephone: Work Telephone:

Fax Number: Email:

NURSING EDUCATION:
Institution
Dates Attended
Major
Degree/Diploma
Date Granted
Overall GPA
CLINICAL EXPERIENCE:
EMPLOYMENT:
Employer: Dates:

Address: City: State: Zip:

Position Held:

Duties:
***This form can only be used to produce a printable copy. No information is transfered to or saved by The Ohio State University at Lima. You must still mail in all application materials.***