Allied Health Program Application
Science, Nursing, And Allied Health
Bossier Parish Community College
Office: (318)678-6110
6220 East Texas Street
Fax: (318) 678-6199
Bossier City, Louisiana 71111
Building B, Room 148
www.bpcc.edu
Bossier Parish Community College Allied Health Programs have a selective admission process. This process is non-
discriminatory on the basis of race, color, national origin, gender, age, qualified disability, marital status, veteran’s status,
or sexual orientation in admission to its programs.
You may type on the form and must print when completed. You WILL NOT be permitted to save the form. Please
complete, print, sign, and return your application to the Program Director by the program’s application deadline in order
to be considered for program selection.
NOTE: It is the student’s responsibility to provide the program director written notification of any contact information
changes. In addition, the student must contact the registrar and complete the appropriate documentation for the change to
be recognized in the school system.
Applicant Information
Date: ___________________ Program Applying for:
Name: ____________________________________________________________________________
Mailing address: ____________________________________________________________________
City: ___________________________ State: ________ Zip/postal code: ______________________
SS Number: _____________________ BPCC Student ID Number: ___________________________
Home Phone: ________________________ Cell Phone: ___________________________________
Personal Email Address: _____________________________________________________________
BPCC Email Address: _______________________________________________________________
Check one:
First time applicant, currently enrolled a BPCC
First time applicant, never attended BPCC
First time applicant, previous BPCC Student
If a previous applicant:
Date Prior Application: __________________
Program: _____________________________
Previous Applicant
Person to notify during school hours in case of emergency:
Name: ________________________ Relationship: _________________ Contacts Telephone: _____________
How did you find out about your program of interest (mark only one)?
Advisor Flyer on class bulletin board
Announcement on myBPCC or electronically Instructor, other than advisor
BPCC sponsored event Radio advertisement
Employer Television advertisement
Fellow classmate or friend Other: _______________________
Previous Education & Experience
Name of School: ___________________________________________________________________________
City & State: _______________________________________________________________________________
Attended: From ____________________ To: _________________________
Major: _____________________ Diploma/Degree: ____________________________________
Name of School: ___________________________________________________________________________
City & State: _______________________________________________________________________________
Attended: From ____________________ To: _________________________
Major: ______________________ Diploma/Degree: ____________________________________
Provide information concerning college, university, vocational or trade schools attended (All official transcripts must
be sent to BPCC):
Name of School: ___________________________________________________________________________
City & State: _______________________________________________________________________________
Attended: From ____________________ To: _________________________
Major: ______________________ Diploma/Degree: ____________________________________
Name of School: ___________________________________________________________________________
City & State: _______________________________________________________________________________
Attended: From ____________________ To: _________________________
Major: ______________________ Diploma/Degree: ____________________________________
If presently enrolled at any other college/university, what courses are you enrolled in?
List other non-traditional educational experiences (travel, military service, on-the-job training, etc.) that you think
may be relevant to helping the Admissions Committees evaluate your application.
______________________________________________________________ _____________________
List your professional and/or business experiences below (optional):
Name of employer: _______________________________ Phone #:______________________________
Address of employer: ____________________________________________________________________
Dates of employment: From _________________ to: ________________________
Position: ____________________________________
Job responsibilities:
Statement of Truth
I, ________________________, am indicating that the information I have included on my application is true. I
understand misrepresentation of omission of information on this application, including my signature, may result in the
loss of eligibility for admission into the Allied Health Program at BPCC for which I am applying.
Applicant’s Signature Date
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signature
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