DEPARTMENT OF RESTORATIVE DENTISTRY
DENTAL LABORATORY TECHNOLOGY PROGRAM
(To be Renamed Restorative Dental Technology Program Fall of 2017)
APPLICATION FOR ADMISSION
Application Period: Year Round
Incomplete Application will not be processed
Print Name: ______________________________________ ____________________________________ ___________________
Last First Middle Initial
Social Security #: ______________________________________________________________________
PCC student Identication numbers are not accepted in place of a social security number
Address: ____________________________________________________________________________________
City: _______________________________________________________________ State: ___________ Zip Code:____________
Cell Phone #:_____________________________________ Home Phone #:_____________________________________
E-mail: ___________________________________________________________________________________________________
One ofcial transcript of all colleges and high school attended and/or GED Certicate (if applicable) must be submitted with
this application. A second ofcial transcript must be sent to the Records Ofce upon acceptance to the Program. The Division
of Health Sciences will not retrieve scanned transcripts.
Mark all documents included with this Application:
____ Ofcial U.S. High School Transcript ____ GED Certicate
____ Foreign Equivalency Report ____ Other _____________________________
Your last name while in high school: _________________________________________________
Are you a U.S. Veteran or spouse of a U.S. Veteran?
____ Yes (please submit a copy of your DD214 with this Application)
____ I am not a U.S. Veteran or spouse of a U.S. Veteran
College degree(s) received:
____ Associates ____ Baccalaureate ____ Masters ____ Doctoral
List all colleges/universities attended:
1. _______________________________________________ 2. _______________________________________________
3. _______________________________________________ 4. _______________________________________________
Ethnic background:
____ Asian/Pacic Islander ____ Black/African ____ American Caucasian, non-Hispanic
____ Hispanic ____ Native American ____ Other: ________________________
____ Decline to state
Have you ever attended a Dental Technology Program and not completed the program?
____ Yes ____ No
If Yes, list the courses completed: ____________________________________________________________________________
I certify that all information on this Application is correct to the best of my knowledge. I understand that any falsication and/or
withholding of information will disqualify this application.
_____________________________________ _______________________________________________ _________________
Previous Maiden Name (if applicable) Applicant’s Ink Signature Date
