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This application is for:
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Fall Enrollment
Spring Enrollment (limited classes available)
Name
*
First
Middle
Last
Address
*
Street Address
Address Line 2
City
State
ZIP / Postal Code
Home Phone
Mobile Phone
Email
*
Enter Email
Confirm Email
Last 4 digits of your SS #
*
Gender
*
Male
Female
Age
*
Date of Birth
*
Date Format: MM slash DD slash YYYY
Legal Resident Of:
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State
Afghanistan
Åland Islands
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darrussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Réunion
Romania
Russia
Rwanda
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
US Minor Outlying Islands
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Country
Citizenship
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Ethnicity
Optional
Asian/Pacific Islander
African American
Caucasian, Non-Hispanic
Hispanic
Native American
Other
Emergency Contact Information
Emergency Contact Name
*
First
Last
Relationship
*
Emergency Contact Phone
Emergency Contact Mobile Phone
Have you requested financial aid?
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Yes
No
Are you receiving financial aid?
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Yes
No
Are you a U.S. Veteran or spouse of a U.S. Veteran?
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If yes, you must provide a copy of DD214
Yes
No
High Schools Attended
Most recent first
High School
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Where you graduated
Attended From
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Date Format: MM slash DD slash YYYY
Attended To
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Date Format: MM slash DD slash YYYY
GPA
*
Graduated with:
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Diploma
GED
Previous High School
Attended From
Date Format: MM slash DD slash YYYY
Attended To
Date Format: MM slash DD slash YYYY
Previous High School
Attended From
Date Format: MM slash DD slash YYYY
Attended To
Date Format: MM slash DD slash YYYY
Colleges Attended
Most recent first
College 1
Attended From
Date Format: MM slash DD slash YYYY
Attended To
Date Format: MM slash DD slash YYYY
Did you graduate from this college?
Yes
No
What degree did you earn from this college?
College 2
Attended From
Date Format: MM slash DD slash YYYY
Attended To
Date Format: MM slash DD slash YYYY
Did you graduate from this college?
Yes
No
What degree did you earn from this college?
College 3
Attended From
Date Format: MM slash DD slash YYYY
Attended To
Date Format: MM slash DD slash YYYY
Did you graduate from this college?
Yes
No
What degree did you earn from this college?
List Honors or Special Achievements and the year received
Have you previously been accepted to a Dental Assisting Program
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Yes
No
Have you previously completed any Dental Assisting Program courses at PCC
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Yes
No
Please list school, year of acceptance, and any courses completed:
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How did you hear about PCC’s Dental Assisting Program?
*
Check all that apply
Through a friend/another dental assistant/dentist
PCC Dental Assisting brochure
Through a graduate from our program High School Counselor/Career Day
PCC Health Careers brochure
Advertisement (movie, newspaper etc)
Health Sciences Division Office
Website
Other
Other way you have heard about PCC's Dental Assisting Program
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Indicate any experiences that would demonstrate your ability to work with your hands
*
Indicate any experiences that would demonstrate your ability to work effectively with people
*
Employment History
Give a summary of your employment history
Name of Company #1
*
From
*
Date Format: MM slash DD slash YYYY
To
*
Date Format: MM slash DD slash YYYY
Position
*
Name of Company #2
From
Date Format: MM slash DD slash YYYY
To
Date Format: MM slash DD slash YYYY
Position
Name of Company #3
From
Date Format: MM slash DD slash YYYY
To
Date Format: MM slash DD slash YYYY
Position
Will you be employed while attending school?
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Yes
No
Work commitment
*
Full Time
Part Time
Current Position
*
Do you have family care responsibilities?
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Yes
No
Indicate your plans upon graduation from the Dental Assisting Program
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Private Practice
Specialty Practice
AS Degree completion
Teaching
Dental School
Dental Hygiene
Military
Other
List any activities in which you have excelled:
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List extracurricular endeavors, community services, and hobbies in which you have participated:
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Describe the major influences in your life:
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Do you have any additional comments that you feel the Admissions Committee should take into consideration when reviewing your application:
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Do you plan on taking the examinations to become licensed as a Registered Dental Assistant?
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Yes
No
Do you plan on taking the examination to become a Certified Dental Assistant (National Certification exam)?
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Yes
No
Do you plan on taking the examination to become an Orthodontic Assistant?
Yes
No
Special Statement
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This program is approved by the Dental Board of California and is accredited by the Commission on Dental Accreditation of the American Dental Association. Upon successful completion of the curriculum, a student is eligible to take the national written (CDA) exam to obtain the Certified Dental Assistant status and the California State board written and practical (RDA) examinations to obtain the Registered Dental Assistant License. Applicants for RDA licensure are required to submit official fingerprints and undergo a criminal history investigation prior to receiving a license. The law provides for denial of licensure if you have been convicted of certain felonies. I understand that checking this box constitutes a legal signature confirming that I warrant the truthfulness of the information provided in this application.