BRISTOL-PLYMOUTH REGIONAL TECHNICAL SCHOOL
BRISTOL-PLYMOUTH REGIONAL TECHNICAL SCHOOL
207 Hart Street, Taunton, MA 02780
POST-SECONDARY
DENTAL ASSISTING PROGRAM
Application for Admission
DIRECTIONS:
1. Complete the application
2. Include a non-refundable application fee of $35.00 to accompany application (cash, money order, debit and credit cards accepted).
3. Forward application and fee to Bristol-Plymouth Dental Assisting Program
4. Two letters of reference (preferably from employers) should be forwarded to the Practical Nurse Program Office, 207 Hart Street, Taunton, MA 02780. If letters from employers are not possible, please ask people who can speak of your dependability and determination.
❖ Admission policy can be found on the Bristol-Plymouth website or by contacting the Practical Nurse Program Office at 508-823-5151, Ext. 240
Name
Last First M.I. Maiden
Address
Street City State Zip Code
Telephone Number ( ) ( ) ( )
Area code Home Area code Work Area code Cell Phone
EDUCATIONAL INFORMATION
High School
Name and address
Dates of Attendance Graduation Date (or) Equivalency Certificate (GED) Date
Post Secondary Education (degree and/or courses or certifications completed or attempted)
Name and address of school
Dates of Attendance Major Degree Certificate
Date Date
Name and address of school
Dates of Attendance Major Degree Certificate
Date Date
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EMPLOYMENT INFORMATION
(Please list last three employers, starting with PRESENT employer)
Name and Address
Dates of Employment to Supervisor
Duties
Name and Address
Dates of Employment to Supervisor
Duties
Name and Address
Dates of Employment to Supervisor
Duties
Please explain why you wish to enter this Dental Assisting Program. This essay is 20% of the total admission score. You may attach one additional 8-1/2 x 11 paper if this space is not adequate. You may type or handwrite your essay. Your signature on the essay page verifies that you are the sole author of this essay.
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I certify that the information submitted on this application is accurate and complete
Signature Date
NOTICE OF NON-DISCIMINATION
Bristol-Plymouth Regional Technical School does not discriminate on the basis of age, sex, disability, economic or housing status, race, color, religion, national origin, sexual orientation, gender identity or expression, ancestry or disability in its admission or access to its programs or activities in accordance with Title VI, Title IX and Section 504.
This area for use by the Dental Assisting Program
Application received Exam results References
Application fee Interview (2)
High School Transcript College Transcript
7/15
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