Dental Assistant Application Name First Last Student ID * Required Student Username MECC Email Program acceptance and offers will be made by email to the student’s MECC email account. Please check your MECC email account regularly, a minimum of once daily.Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell PhoneType of Current CPR Card (provider and course) (If applicable)Date CPR Card Expires MM slash DD slash YYYY (If applicable)Upload Copy of CPR Card HereMax. file size: 50 MB.(If applicable)High School Name Date Graduated or GED Completed MM slash DD slash YYYY Please upload a copy of your high school diploma or GED certificate and have an official high school transcript sent to MECC's Enrollment Services.Max. file size: 50 MB.Are you a medical professional? Yes No Please upload a current copy of certification or licensure.Max. file size: 50 MB.Educational HistoryColleges AttendedDates AttendedDegrees ReceivedHave you been convicted of a felony involving a sexual crime OR have you ever been convicted of any other felony under the laws of Virginia or of the United States within the last five (5) years? Yes No I understand after submission I will contact Emily Bowen, program director by email at ebowen@mecc.edu to verify my program application has been received. She will be glad to confirm. Confirmation of the receipt of your program application is the responsibility of the student. * Required Please check Official Signature * RequiredI understand that all information on this application is subject to verification and I consent to a criminal history background check and drug screen. I understand that falsification of any portion of this application may be reason for my withdrawal from the Dental Assistant program. I certify the above stated information is accurate to the best of my knowledge.Date * Required MM slash DD slash YYYY
