SANTA FE COMMUNITY COLLEGE - DOC

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					                                          SANTA FE COMMUNITY COLLEGE
                                             Medical Assistant Program

                                               APPLICATION FOR ADMISSION
                                                                                                            _________________
                                                                                                            Date of Application
Please print in ink and answer all questions
                                                                                                            ________________
                                                                                                            A#

Name: ______________________________________________________________________________________
         (Last)                         (First-legal)              (Middle Initial)                     (Maiden)

Mailing Address: ______________________________________________________________________________
                      Street/P.O. Box                                City                           State            Zip Code

Telephone: ____________________________________                               ______________________________________
                               (Home)                                                      (Work/Message)

Cell phone:________________________________ E-mail address:_____________________________________

Person to contact in case of emergency: ________________Relationship:____________Phone #_________

High School last attended:_______________________________ _______________ ___________________
                               Name of School                     City/State

Did you graduate?       Yes ____ No ____                  If no, GED? ____ (Official transcript must be on file.)


Colleges attended, including SFCC.                 (Official transcripts must be on file for each college except SFCC)

COLLEGE                                         City/State               Units/Credits        GPA           Degree Earned
                                                                            Completed
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

I am (check one):

_____ Currently enrolled at SFCC

_____ Transferring to SFCC from another college

_____ Returning to SFCC after one or more semesters of absence

_____ Returning to the SFCC Medical Assisting Program after one or more semester absence

If you are a returning student in the SFCC Medical Assistant Program, then why did you drop/discontinue the
program and when? Please write in detail.

_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________




SFCC Medical Assistant Program Rev: 06/2008 Sheffield
                                                                                                                         Page 1 of 3
If you are a returning student to the Medical Assisting Program, what are your reasons for returning or
continuing back with the medical assistant program. Please write in detail.

_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________


ENG 111 completed: Yes_____                     No______          Other English course?______

Have you been licensed or certified to practice in any field of health care?                       Yes _____ No _____

If yes, please describe:
Licensed/Certified as: _____________ Date Licensed/Certified: __________ Expiration date: ______

Have you ever been convicted of a felony? Yes _____ No _____

NOTE: Individuals who have been convicted of a felony may not be eligible for licensure or certification in the
health care field. It is the applicant’s responsibility to contact the licensing board or certifying agency in the
state where he/she plans to seek licensure to verify eligibility for licensure or certification prior to making
application to the program.

RESIDENCY DATA

Please list below your places of residence (including dates) for the past 10 years.

Street Address                           City                           State     Dates
__________________________ ____________________ ______ _______________________

__________________________ ____________________ ______ _______________________

__________________________ ____________________ ______ _______________________

__________________________ ____________________ ______ _______________________

STATISTICAL DATA (Used for accreditation purposes only)

The items listed below are for statistical purposes only and are not used in the determination of eligibility for
admission to the Medical Assisting Program.

Gender:               Female ____        Male ____                      Date of Birth_________________

Ethnicity:            Native American/Alaskan Native ____ Native Hawaiian/Other Pacific Islander _____
                      African American/Black _____        Hispanic/Latin _____
                      White _____ Asian _____             Other ____________________________________

Santa Fe Community College is committed to providing equal education and employment opportunity regardless of gender, marital
status, sexual orientation, color, race, religion, age, national origin or disability. Equal educational opportunity applies to admission,
recruitment, extracurricular programs and activities, access to course offerings, counseling, testing, financial assistance and employment.

          I CERTIFY ALL THE ABOVE STATEMENTS TO BE CORRECT AND TRUE.

          _________________________________________________                                 _____________________________
          Signature                                                                         Date



Please mail Application to the Director of the Medical Assistant Program:
Santa Fe Community College, 6401 Richards Avenue, Santa Fe NM 87508



SFCC Medical Assistant Program Rev: 06/2008 Sheffield
                                                                                                                                   Page 2 of 3
                                                 Employment History*

Name of            City        State         Date       Date     Responsibilities           Number
Employer                                     from       to                                  of
                                                                                            Hours/
                                                                                            week




                       *A resume may be submitted along with the Employment History form.




SFCC Medical Assistant Program Rev: 06/2008 Sheffield
                                                                                                     Page 3 of 3

				
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