Fillable Physical Therapist Assistant Program Application (Bossier Parish Community College)

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Physical Therapist Assistant Program Application (Bossier Parish Community College)

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U.S.A. forms for Bossier Parish Community College

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Science
, Nursing, And Allied Health
Office: (318)678-6110
Fax: (3
18) 678-6199
Building B, Room 148
Bossier Parish Community College
6220 East Texas Street
Bossier City, Louisiana 71111
www.bpcc.edu
Physical Therapist Assistant Program Application
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: __ Gender:
BPCC Email Address:
Check as applicable: If a previous applicant:
First time applicant, currently enrolled at BPCC Previous Applicant
First time applicant, never attended BPCC Date Prior Application:
Also applying to :
Person to notify during school hours in case of emergency:
Name: Relationship: Contact’s 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
se
nt 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?
Lis
t other non-traditional educational experiences (travel, military service, on-the-job training, etc.) that you think may
be re
levant to helping the Admissions Committees evaluate your application.
List your professional and/or business experiences below (optional):
Nam
e of employer: _______________________________ Phone #:
Address of employer:
Dates of employment: From _ to:
Position:
Job responsibilities:
PTA Applicant Disclosures:
Please answer each of the following questions by clicking the appropriate answer. Yes No
1. Have you ever been dropped, suspended, placed on probation, expelled,
requested to leave temporarily, resign or otherwise been acted against by any
post-secondary educational program or professional training program in which
you were enrolled prior to completion of that training?
2. Have you ever had an application for any professional license refused or denied
by any licensing authority?
3. Have you ever had a license or certification revoked or suspended, other
discip
linary action taken, by any professional licensing authority or any state,
territory or country?
4
Have your practice privileges ever been restricted or terminated by any licensing
authorit
y, association, licensed facility, or staff of such facility, or have you ever
voluntarily or involuntarily resigned or withdrawn from such association or avoid
imposition of such measure?
.
5. Have you ever been charged with, convicted or pled guilty or nolo contendere, to
a felony criminal offense in any state or federal court, whether or not sentence
has been imposed or suspended?
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 D
ate
If you have answered yes to any questions, all YES answers MUST be explained on a separate SIGNED and
NO
TORIZED affidavit. The affidavit should include all relevant dates and identify the relevant jurisdiction
and/or entity involved. Failure to disclose any of the requested information may result in the denial of your
application.
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Physical Therapist Assistant Program Application (Bossier Parish Community College)

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Completed 17 September 2020

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