Florida State College ... - Florida State College at Jacksonville

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					                   This application is to be completed, signed and included in the application packet.

                                                   Florida State College
                                               Occupational Therapy Assistant
                                                   Program Application

                                           Application Deadline: May 27, 2011
                                Incomplete and/or late applications will not be processed.

Legal name only              Last                                       First                                 Middle             Maiden

*Social Security #:_________________________________________
*In compliance with Florida Statute 119.071(5), Florida State College at Jacksonville issues this notification regarding the purpose of the collection
and use of Social Security numbers. Florida State College will collect your Social Security Number (SSN) for record identification, state and federal
reporting. Providing your SSN on this application means that you consent to the use of your number in the manner described. If you choose not to
provide your SSN, you will be provided an alternate identification number. All Social Security Numbers are protected by Federal regulations and are
not to be released to unauthorized parties. Read more about the collection and use of social security numbers (

Mailing Address:_____________________________________________________________________
                                                         Street / Apt #

          City                                                State                          Zip                              County

Preferred telephone number: _______________________________________                                                    cell     home          other

Alternate telephone number: ________________________________________                                                   cell     home          other

E-mail address: ____________________________________________

Previous Education

    High School: ___________________________________________________________________ or
                                    Name                                    City, State                              Graduation Year

   Equivalency Diploma:________________________________________________________________
                                             Issuing Agency                                  City and State                            Date

   Have you completed a college degree?                       _______ No               _________ Yes             If yes complete:

      Highest degree earned                             Institution                                   City, State                  Year

CPR Certification

______ Yes, I am currently certified. ______________________________________________________
                                                               Type of certification                                      Expiration date

______ No, I am not currently certified.

Overall Cumulative GPA: ____________________
   GPA can be found on your transcript
Page 2 of 2                                                                                                                Florida State College OTA Program Application                             2011

General Education Courses:
Write completed course grade earned in appropriate box.
If you are currently enrolled in the course place an “X” in the appropriate box.
Remember to highlight the course and grade on your Florida State College transcript.
                                                                                      Prerequisite Courses
                                                                                                                                                       Currently                   Do not write
                                                 Title                                                         Grade Earned                                                           below
ENC 1101 - English Composition I

PSY 1012 - General Psychology

BSC 2085C - Human Anatomy and Physiology I

Mathematics Course: _____________________
Refer to A.S. degree General Education Requirements
Recommended course: MAC 1105 - College Algebra
                                      Additional Courses
SPC 2065 - Speech Communication for
Business and the Professions
or ENC 1102 Writing About Non-Fiction
DEP 2004 - Human Growth and Development

BSC 2086C - Human Anatomy and Physiology II

Humanities Course: ______________________
Refer to A.S. degree General Education Requirements
                                                PSB Health Occupations Aptitude Examination (HOT Test)
                            According to your test record and profile chart, write the percentile for the following sections.
                                                                                                                          Do not write
                              Examination Section                                        Percentile
Academic Aptitude - Total
Reading Comprehension
Information in the Natural Sciences

           **COUNTRY OF CITIZENSHIP: ______________________________________________

           **AGE: ____________________                            DATE OF BIRTH: ____________________________

           **RACE:          (    ) Black (not of Hispanic origin)                              (    ) White (not of Hispanic origin)                     (    ) Asian or Pacific Islander

                            (    ) American Indian or Alaskan Native                           (    ) Hispanic                                           (    ) Other

           **SEX:            (    ) Male            (    ) Female

           **The use of this information is to submit data as requested by State and Federal Government and Accrediting Agencies.
           This information is not considered in the admission process and will not be used to discriminate against any applicant.

I certify I have read all the instructions, and the information contained in this application and its attachments
is true and accurate.
Signature: __________________________________________                                                                                         Date: _____________

                                                              Florida State College at Jacksonville is a member of the Florida State College System.
                                         Florida State College at Jacksonville is not affiliated with any other public or private university or College in Florida or elsewhere.
       Florida State College is a division of Florida State College at Jacksonville. Florida State College at Jacksonville is accredited by the Commission on Colleges of the Southern Association of Colleges
         and Schools (“SACS”) to award the baccalaureate and associate degree. Contact the Commission on Colleges at 1866 Southern Lane, Decatur, Georgia 30033-4097, or call (404) 679-4500 for
                                                                        questions about the accreditation of Florida State College at Jacksonville.

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