Verification of Optional Community Service
(Volunteer work in a dental office is not counted as a Community Service)
100 Hours Required within Past 2 Years
Supervisor or Phone Numbers
Date of Organization and Hours
Contact Person
for Verification
Activity
Description of Activity Worked
(Required) (Required)
These hours must be completed within the previous two years of submission of the application to
the Dental Hygiene program. Make additional copies as necessary.
Columbia Basin College complies with the spirit and letter of state and federal laws, regulations and executive orders pertaining to civil rights, Title IX, equal opportunity and affirmative action. CBC does not discriminate on the ba-
sis of race, color, creed, religion, national or ethnic origin, parental status or families with children, marital status, sex (gender), sexual orientation, gender identity or expression, age, genetic information, honorably discharged veteran or mil-
itary status, or the presence of any sensory, mental, or physical disability, or the use of a trained dog guide or service animal (allowed by law) by a person with a disability, or any other prohibited basis in its educational programs or employ-
ment. Questions or complaints may be referred to the Vice President for Human Resources & Legal Affairs and CBC’s Title IX/EEO Coordinator at (509) 542-5548.Individuals with disabilities are encouraged to participate in all college
sponsored events and programs. If you have a disability, and require an accommodation, please contact the CBC Resource Center at (509) 542-4412 or the Washington Relay Service at 711 or 1-800-833-6384. This notice is available in alternative media by request.
Applicant Name Phone Number
Columbia
~
Basin
College
BASDH - Dental Hygiene Program
Application for Admission
