Work Verification Form - LPN-AASN Program Option
Arkansas State University – School of Nursing
LPN – AASN Program Option
Employer Documentation of Work Experience
Student Name: ___________________________________________________________ A-State Student ID#: _____________________________________
The applicant MUST provide proof of work experience reflecting a minimum of 1,000 hours employed as a licensed practical nurse during the past 12-24 months in an acute or long-term care setting. The form MUST be signed by the Human Resource Representative or Registered Nurse Supervisor and returned to the School of Nursing by the employer. The form may be returned by postal mail or email from the employer. If returned by postal mail, then a facility envelope must be used with a signature across the seal. An email submission must be from an employer email address, not a personal email address. Please use the instructions below for submission by postal mail or email.
**Note: If documentation of work experience is not submitted properly, the student’s application will be incomplete.**
My signature below confirms that ___________________________________ has completed over ____________ hours work within the past
_________ years at the facility indicated below. All hours counted were performed under the direction of a registered nurse.
Name of Institution: __________________________________________________________________________________
Address: ________________________________________________________________
City/State/Zip: ________________________________________________________________ Telephone: _________________________________
Signature: ________________________________________________________________________ Date: ________________________
Title of Person Completing Form: ___________________________________________________________________________________________
Mail to:
A-State School of Nursing
Attention: LPN-AASN Admission Committee
P.O. Box 910
State University, AR 72467
Email to: