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Burlington County College |
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APPLICATION
FOR ADMISSION *************************PLEASE PRINT AND MAIL TO
ADDRESS ABOVE*********************** PROGRAM OF
INTEREST (Please Indicate which program you are applying to): ____
Health Information
Technology
Semester/year you plan to
begin HIT courses _____________
____ Cancer Registry Certificate Program BIOGRAPHICAL DATA
(Please Print) NAME:
________________________________
________ _________________________________________ SOCIAL SECURITY
#: ____ ____ ____- ____ ____ -____
____ ____ ____ ADDRESS:_______________________________________________________________________ CITY:
___________________________________STATE:_____________ZIP:______________ HOME PHONE #:
( )
____ ____ ____ - ____ ____ ____ ____ WORK
PHONE #: (
) ____ ____ ____ - ____ ____ ____ ____ (Optional) CELL
PHONE #: (
) ____ ____ ____ - ____ ____ ____ ____ EMAIL
ADDRESS:
_________________________________________ ACADEMIC
DATA Please note:
Official transcripts must be sent to the College Admissions Department HIGH SCHOOL
(Name): __________________________________
CITY:_____________________STATE: _______ GRADUATION DATE:
_______________________ GED
DATE: _______________________ COLLEGE (Name):
______________________________________CITY:_____________________STATE:
________ MAJOR:
________________________________ DEGREE: ____________ YEAR
OF GRADUATION: ___________ COLLEGE (Name):
______________________________________CITY:_____________________STATE:
________ MAJOR:
________________________________ DEGREE: ____________ YEAR
OF GRADUATION: ___________ EMPLOYMENT DATA: Current
Employer: ________________________________________________________________________ Address:
________________________________________________________________________________ Job Title:
________________________________________________________________________________ ________________________________________________________________________________________ Previous
Employer: ________________________________________________________________________ Address:
________________________________________________________________________________ Job Title:
________________________________________________________________________________ Duties &
Responsibilities:
___________________________________________________________________ Work Telephone
#: ( ) ____ ____
____ - ____ ____ ____ ____ (Optional) Previous
Employer: ________________________________________________________________________ Address:
________________________________________________________________________________ Job Title:
________________________________________________________________________________ Duties &
Responsibilities: ___________________________________________________________________ ________________________________________________________________________________________ Work Telephone
#: ( ) ____ ____
____ - ____ ____ ____ ____ (Optional) BURLINGTON COUNTY
COLLEGE EDUCATION Are you now a
student at
BCC?
YES NO ALLIED HEALTH
ENTRANCE EXAM PSYCHOLOGICAL
SERVICES BUREAU (PSB) EXAMINATION - LIST DATES FOR ALL SESSIONS YOU HAVE
TAKEN OR PLAN TO TAKE: _______/_______/_______
_______/_______/_______
_______/_______/_______ ESSAY QUESTIONS In addition to
you admission application, please submit responses to the following questions
in essay format:
1. Why have you chosen to pursue a career in health
information (or Cancer Registry, Coding) and what
2. What is it about yourself that makes you an outstanding
applicant to the health information technology CERTIFICATION:
I certify that
the statements on this application are true and acurate to the best of my
knowledge: APPLICANTS
SIGNATURE:___________________________________ DATE:
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