COLLEGE APPLICATION FORM

Thank you for your interest in becoming associated with Bethesda College of Health Sciences Nursing or Radiography Program. Please complete this application in full to help us learn about your experience and abilities. Applicants are accepted into the program without regard to race, color, religion, national origin, sex, age, handicap or other similar factors that are not program-oriented.

General Information


XXX-XX-XXXX

If different from above


used in transcript request form

used in transcript request form

used in transcript request form

used in transcript request form

Education

High School/GED

College/Institution:#1


(Month/Year)

(Month/Year)

College/Institution:#2


(Month/Year)

(Month/Year)

College/Institution:#3


(Month/Year)

(Month/Year)

College/Institution:#4


(Month/Year)

(Month/Year)

Have you ever been convicted/charged of a felony or misdemeanor; or pleaded nolo contendere (no contest) to a felony or misdeameanor; or pleaded nolle prosequi (prosecution abandoned); or pleaded guilty to a felony or misdemeanor; or been found guilty of a felony or misdemeanor or have felony or misdemeanor charges pending against you? (Include any and all instances of the foregoing even if adjudication was withheld).

Degree Information

(Admission to the college does not guarantee admission to your desired program)

Applicant Information

In Case of Emergency

Employment Information

Please start with the most recent job and fill out the employment information in descending order.

Employment # 1

Employment # 2

Employment # 3

Professional/Employment Reference Details

Reference # 1

Reference # 2

Reference # 3

Please submit a 250-word essay regarding interest in becoming a Nurse/Radiographer. (Please put your full name on your essay and make sure its in Word format before uploading your document)

Application & Background Check Certification

I authorize reference checks and background investigation of all statements contained in this application. I understand my attendance in BETHESDA COLLEGE OF HEALTH SCIENCES NURSING/RADIOGRAPHY PROGRAM is contingent upon this verification. I further understand that my training may be terminated if I fail to comply with the Program and College policies and procedures. I also understand and agree that all items of College property will be returned to the school or paid for prior to leaving BCHS. I understand that if I fail to answer any question; falsify the answer to any questions; fail to provide information which might make any answers to this application misleading; or enter incorrect information; this alone may result in a refusal to accept me in the program or result in my dismissal from the program if I have already been accepted.

Background Investigation - Acknowledgment & Authorization

NOTICE AND ACKNOWLEDGMENT
(IMPORTANT -- PLEASE READ CAREFULLY BEFORE SIGNING ACKNOWLEGMENT)

NOTICE REGARDING BACKGROUND INVESTIGATION

BETHESDA COLLEGE OF HEALTH SCIENCES may obtain information about you from a consumer reporting agency for enrollment purposes. This request may make you the subject of a e-consumer report which may include information about your character, general reputation, criminal record, employment, education, driving record, and/or other characteristics of your current and past history. This request may involve personal interviews with sources such as your current and past employers, friends, or associates. Requests may be obtained before acceptance to the program and, if you are accepted, throughout the program, and after termination for wrongful activity in direct relation to this program, as prescribed by law. You have the right, upon written request made within a reasonable time after receipt of this notice, to request disclosure of the nature and scope of any investigative consumer report. Credential Check Corp. will perform searches from various sources and compile the results in to a final report to our client. Sources will vary by search type, may include information from third parties, and are performed as prescribed by law, the Fair Credit Reporting Act (FCRA), and state law governing employment background screening/investigation. Credential Check Corp. is located at P.O.Box 4504 Troy, MI.

ACKNOWLEDGMENT AND AUTHORIZATION

I acknowledge receipt of the NOTICE REGARDING BACKGROUND INVESTIGATION and A SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of these documents. I hereby authorize the obtaining of "consumer reports" and/or "investigative consumer reports" at any time after receipt of this authorization and, if I am accepted in the Nursing or Radiography program, and throughout my education in this program. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, or insurance company to furnish any and all background information requested by Credential Check Corp, or another outside organization acting on behalf of Credential Check Corp. I agree that a facsimile (Fax) or photographic copy of this Authorization shall be as valid as the original.

The application fee is due at the time of submission of the application. The application will not be deemed "Submitted", and review of the application will not begin, until the applicant has paid the application fee.


(First, Middle, and Last)

(if applicant is under 18 years old.)
Required