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Office of Continuing Education:
Legal Nurse Consultant Program


Registration is now open for the Autumn 2014 Legal Nurse Consultant Program to be held in the Toledo/Perrysburg area.

Autumn 2014

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.***