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Office of Continuing Education:
Legal Nurse Consultant Program


Registration is now closed for the Autumn 2014 Legal Nurse Consultant Program. Please check back for dates and location for the Spring 2015 session.

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.***