. List your relevant employment experiences over the past 10 years, including military service. Add additional sheet if necessary.
1. ________________________________________________________________________FROM_______TO_______ ________________________
2. ________________________________________________________________________FROM_______TO_______ ________________________
3. ________________________________________________________________________FROM_______TO_______ ________________________
10. Are you reapplying for this program? Yes_____ No _____. If yes, when did you last apply?__________________________________________________
11. Are you a veteran of the US Military Service? Yes _____ No _____. If YES, are you eligible for and certified by the Veterans Administration for education
benefits? Yes _____ No _____ If YES, attach page to this application and give branch of service, dates entered and separated from service, rank at time of
separation and type of discharge.
2. Are you a member of the National Guard or Reserve? Yes_____ No _____. If YES, attach page to application and give branch, days and number of meetings
attended each month.
3. Have you ever been suspended or dismissed from any college or university for scholastic or disciplinary reasons? Yes_____ No_____. If YES, give name of
institution, date and reason for this action. ___________________________________________________________________________________________
4. Have you applied for admission to other Allied Health Programs at Delgado? Yes_____ No_____. If YES, give the program name and dates.
15. Are you a U.S. Citizen? Yes_____ No _____.
6. Optional Response: If you have a disability, describe on a separate page any special equipment, architectural modifications, or other factors which would have to
be considered by you and by the School/department in planning your educational experience at Delgado Community College if you are accepted for admission.
ALL APPLICANTS PLEASE READ CAREFULLY AND SIGN THE FOLLOWING
Other than a minor traffic violation, have you ever been convicted of a felony? Yes_______ No _______ If yes, please explain on additional page.
I UNDERSTAND THAT THE INFORMATION SUBMITTED ON THIS APPLICATION FOR ADMISSION TO DELGADO COMMUNITY COLLEGE’S ALLIED
HEALTH PROGRAM IN MY NAME WILL BE RELIED UPON BY DELGADO COMMUNITY COLLEGE OFFICIALS TO DETERMINE MY STATUS FOR
ADMISSION ELIGIBILITY. I AUTHORIZE DELGADO COMMUNITY COLLEGE OFFICIALS TO VERIFY ANY INFORMATION I HAVE PROVIDED. I
FURTHER AUTHORIZE ANY AND ALL EDUCATIONAL INSTITUTIONS, GOVERNMENTAL AGENCIES, AND PRIVATE EMPLOYERS THAT I HAVE
ATTENDED, WORKED FOR, OR WHO MAINTAIN RECORDS RELATED TO ME TO RELEASE SUCH INFORMATION TO DELGADO COMMUNITY
I AGREE TO NOTIFY DELGADO COMMUNITY COLLEGE’S ALLIED HEALTH ADMISSIONS OFFICE OF ANY CHANGES TO THE INFORMATION
I CERTIFY THAT THE INFORMATION IN THIS APPLICATION IS COMPLETE AND CORRECT AND UNDERSTAND THAT SUBMISSION OF FALSE,
INCOMPLETE, OR INCORRECT INFORMATION IS GROUNDS FOR REJECTION OF MY APPLICATION, WITHDRAWAL OF ANY ACCEPTANCE OFFER,
CANCELLATION OF ENROLLMENT, OR APPROPRIATE DISCIPLINARY ACTION. I UNDERSTAND IT IS ALSO NECESSARY TO COMFORM TO THE
PROGRAM’S TECHNICAL STANDARDS AND REQUIREMENTS CONCERNING A PHYSICAL EXAMINATION.
IF ACCEPTED, I AGREE TO ABIDE BY AND
OBSERVE ALL PROGRAM AND AFFILIATE HOSPITAL POLICIES, RULES AND REGULATIONS, AS AMENDED FROM TIME TO TIME.
I ALSO UNDERSTAND THAT THIS APPLICATION IS FOR THIS PROGRAM ONLY. IF I ENTER DELGADO COLLEGE, I MUST FILL OUT AND SUBMIT
A DELGADO COLLEGE APPLICATION FOR ADMISSION. COMPLETION OF THIS FORM DOES NOT INDICATE THAT YOU ARE ACCEPTED INTO
Signature of Applicant Date
For classes starting in January (spring), the deadline is October 1st. When classes begin in August (fall), the deadline is June
15th. For more information, please contact the Program Director, Robin Wegener at 504-671-6230 or firstname.lastname@example.org
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