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

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