Competitive Selection File Review Request Form

Attach all required documents for the Competitive Selection File Review Request.

The file review will not be processed if it is incomplete or missing the required documents. If you forget to attach the proper documentation, you must submit an updated Competitive Selection File Review Request by the posted deadline.

Name*

First NameLast Name

Student ID*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Area CodePhone Number

WGTC Email Address*

example@student.westgatech.edu

Which competitive selection program are you applying for?*

Review your Self-Service Web student information and indicate your current residency status.*

Are you in good academic standing with WGTC?*

YesNo

Have you submitted an official transcript from each college previously attended?*

YesNoNot applicable

Do you hold a current CPR Certification by the American Heart Association for Healthcare Providers (Required for all programs EXCEPT Medical Laboratory Technology)?*

YesNo

CPR Certification Expiration Date*

Date

Attach a copy of the front and back of your certification card*

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Student may apply to only one Nursing or Health Science program and at only one location per selection period. A student who attempts to apply to more than one program or more than one location will not be included in the competitive selection process.

Select a campus*

Coweta - February 1 application deadlineMurphy - June 1 application deadlineLaGrange - September 1 application deadline

Have you completed the Test of Essential Academic Skills (TEAS) exam with a minimum 75% Adjusted Individual Total Score and an individual score of 65% on each section (Reading, Math, Science, English, and Language Usage)?*

YesNo

Beginning July 1, 2019, a maximum of two attempts will be allowed per calendar year, with a minimum of 30 days between attempts. Official exam score report must be attached and current within two (2) years. Upload a copy of your scores here:*

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Applicant must possess a current State Certified Nursing Assistant Certification (CNA) or be a Licensed Practical Nurse (LPN), obtained within the last (5) years. If the certification or license was issued more than (5) years, the applicant must have worked as a CNA or LPN for a minimum of one year within five years of the cohort start date.

Do you possess a current State Certified Nursing Assistant Certificate?*

YesNo

Please provide your CNA issue date, or anticipated issue date:*

Date

Are you a current Licensed Practical Nurse?*

YesNo

If yes, please provide your LPN issue date:*

Date

Copy of the State Certified Nursing Assistant Certificate or a copy of the Practical Nurse License must be attached.*

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If your credential (CNA or LPN) was issued more than five (5) years prior to the cohort start date, do you have a minimum of one (1) year work experience within the last five (5) years?*

YesNoNot applicable

If your CNA or LPN was issued more than five (5) years prior to the cohort start date, please attach employer documentation showing at least one (1) year of work experience within the last five (5) years:

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The Associate Degree Nursing program requires the following courses to be completed by the application deadline. Each course must be completed with a minimum grade of C. In addition to earning a minimum grade of C in each course, an overall GPA of 3.2 must be earned in the required courses. Specific technical, science, and Health Science courses must be completed within seven years of the program cohort start date.

Please identify where and when each course was completed, and the letter grade attained. If you repeated a required course, please list information relative to the highest grade achieved. WGTC must have an official transcript on file for each college previously attended. Please view your WGTC academic history through Self-Service BANNER Web to find the dates and grades for specific courses completed with WGTC.

Required Courses*

	College Where Completed	Date Completed	Letter Grade Earned
BIOL 2113*
BIOL 2113L*
BIOL 2114*
BIOL 2114L*
ENGL 1101
MATH 1111
PSYC 1101

*Course must be completed within the seven years of the program cohort start date.

In addition to the courses listed above, A student must complete BIOL 2117 and BIOL 2117L with a minimum grade of C within seven years preceding the program cohort start date. Although the courses are not required to be completed prior to the application deadline, they must be completed before the RN cohort begins.

Have you completed BIOL 2117 and BIOL 2117L with a minimum grade of C?*

YesNo

Are you currently enrolled in BIOL 2117 and BIOL 2117L?*

YesNo

If you have completed BIOL 2117 and BIOL2117L, please list the college where enrolled, as well as the dates of completion. If you are currently enrolled in BIOL 2117 and BIOL2117L, list the anticipated dates of completion.*

	College Where Completed	(Anticipated) Date of Completion	Letter Grade Earned
BIOL 2117*
BIOL 2117L*

*Course must be completed within the seven years of the program cohort start date.

Bonus points are available in the selection process. Please indicate (yes or no) if you are requesting additional points for any of the following. (Maximum three (3) bonus points available):

A. One (1) point for 6 months of clinical work experience. Clinical experience is defined as actual patient care that includes the delivery of physical care such as certified nursing assistant, nurse aide, licensed practical nurse, patient care technician, medical assistant, surgical technician, back office worker in a clinic or physician’s office, or emergency medical technician.*

YesNo

If yes, submit an employer letter below on company letterhead, include dates of employment, job title, and a brief description of duties for consideration*

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B. Two (2) points for current Licensed Practical Nurses (LPN). A copy of the State Certified Nursing Assistant Certificate or a copy of the Practical Nurse License must be submitted above*

YesNo

C. One (1) point for completion of the Nurse Aide Certificate program, including ALHS 1040, ALHS 1060, ALHS 1090 and NAST 1100*

YesNo

If you have completed ALHS 1040, ALHS 1060, ALHS 1090 and NAST 1100, please list the college where enrolled, as well as the date of completion for the bonus point. *

	College Where Completed	Date of Completion	Letter Grade Earned
ALHS 1040*
ALHS 1060
ALHS 1090*
NAST 1100

*Course must be completed within the seven years of the program cohort start date.

I understand that this request, along with all course information and supporting transcripts, test results, and copy of current CPR card, must be received by the application deadline. I also understand that completion of these courses and meeting other minimum requirements does not guarantee selection as there are a limited number of seats available in the occupational and clinical courses, and selection is based on the competitive selection process.

Signature*

Clear

Date*

Date

Select a campus*

Coweta - November 11 application deadlineLaGrange - June 1 application deadline

Have you completed the Test of Essential Academic Skills (TEAS) exam with a minimum 75% Adjusted Individual Total Score and an individual score of 65% on each section (Reading, Math, Science, English, and Language Usage)?*

YesNo

Beginning July 1, 2019, a maximum of two attempts will be allowed per calendar year, with a minimum of 30 days between attempts. Official exam score report must be attached and current within two (2) years. Upload a copy of your scores here:*

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Applicant must possess an active unencumbered Georgia and/or eNLC Practical Nurse (LPN) Licensure obtained within the last (5) years with at least one to two years of work experience as an LPN. If the license was issued more than (5) years, the applicant must have worked as an LPN for a minimum of one year within five years of the cohort start date. An employer letter of verification must be submitted on company letterhead and include the dates of employment, job title, and a brief description of duties.

Are you a current Licensed Practical Nurse?*

YesNo

If yes, please provide your LPN issue date:*

Date

A copy of the unencumbered Georgia and/or eNLC Practical Nurse License must be attached *

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If the LPN and/or eNLC licensure was issued more than five (5) years prior to the cohort start date, do you have a minimum of one (1) year work experience within the last five (5) years?*

YesNoNot applicable

If your LPN license was issued more than five (5) years prior to the cohort start date, please attach employer documentation showing at least one (1) year of work experience within the last five (5) years:

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The Practical Nursing to Associate Degree Bridge Nursing Bridge program requires the following courses to be completed by the application deadline. Each course must be completed with a minimum grade of C. In addition to earning a minimum grade of C in each course, an overall GPA of 3.2 must be earned in the required courses. Specific technical, science and Health Science courses must be completed within seven years of the program cohort start date.

Please identify where and when each course was completed, and the letter grade attained. If you repeated a required course, please list information relative to the highest grade achieved. WGTC must have an official transcript on file for each college previously attended. Please view your WGTC academic history through the Self-Service BANNER Web to find the dates and grades for specific courses completed with WGTC.

Required Courses*

	College Where Completed	Date Completed	Letter Grade Earned
BIOL 2113*
BIOL 2113L*
BIOL 2114*
BIOL 2114L*
ENGL 1101
MATH 1111
PSYC 1101
BIOL 2117
BIOL 2117L
PSYC 2103

*Course must be completed within the seven years of the program cohort start date.

Did you graduate from the West Georgia Technical College Practical Nursing Program?*

YesNo

I understand that this request, along with all course information and supporting transcripts, test results, and copy of current CPR card and LPN and/or eNLC licensure, must be received by the application deadline. I also understand that completion of these courses and meeting other minimum requirements does not guarantee selection as there are a limited number of seats available in the occupational and clinical courses, and selection is based on the competitive selection process.

Signature*

Clear

Date*

Date

Select a campus*

Coweta - September 1 application deadlineMurphy - June 1 application deadlineLaGrange - February 1 application deadline

Have you completed the Test of Essential Academic Skills (TEAS) exam with a minimum 65% Adjusted Individual Total Score?*

YesNo

Beginning July 1, 2019, a maximum of two attempts will be allowed per calendar year, with a minimum of 30 days between attempts. Official exam score report must be attached and current within two (2) years. Upload a copy of your scores here:*

Browse Files

The Practical Nursing program requires the following courses to be completed by the application deadline. Each course must be completed with a minimum grade of C. In addition to earning a minimum grade of C in each course, an overall GPA of 3.0 must be earned in the required courses. Specific technical, science, and Health Science courses must be completed within seven years of the start of the program cohort start date.

Please identify where and when each course was completed, and the letter grade attained. If you repeated a required course, please list information relative to the highest grade achieved. WGTC must have an official transcript on file for each college previously attended. Please view your WGTC academic history through Self-Service BANNER Web to find the dates and grades for specific courses completed with WGTC.

Required Courses*

	College Where Completed	Date Completed	Letter Grade Earned
ALHS 1090*
ALHS 1011* - see table below for alternatives
ENGL 1010 OR
ENGL 1101
MATH 1012 OR
MATH 1101 OR
MATH 1111 OR
MATH 1113
PSYC 1010 OR
PSYCH 1101

*Course must be completed within the seven years of the program cohort start date.

In lieu of ALHS 1011, ALL FOUR of the following courses together may be taken as an alternative (all four must be taken with a minimum grade of C):

	College Where Completed	Date Completed	Letter Grade Earned
BIOL 2113
BIOL2113L
BIOL 2114
BIOL2114L

I understand that this request, along with all course information and supporting transcripts, test results, and copy of current CPR card, must be received by the application deadline. I also understand that completion of these courses and meeting other minimum requirements does not guarantee selection as there are a limited number of seats available in the occupational and clinical courses, and selection is based on the competitive selection process.

Signature*

Clear

Date*

Date

Select a campus*

Murphy

The Medical Laboratory Technology program requires the following courses to be completed by the application deadline. Each course must be completed with a minimum grade of C. In addition to earning a minimum grade of C in each course, an overall GPA of 3.0 must be earned in the required courses. Specific technical, science, and Health Science courses must be completed within seven years of the start of the program cohort start date.

Please identify where and when each course was completed, and the letter grade attained. If you repeated a required course, please list information relative to the highest grade achieved. WGTC must have an official transcript on file for each college previously attended. Please view your WGTC academic history through Self-Service BANNER Web to find the dates and grades for specific courses completed with WGTC.

Required Courses*

	College Where Completed	Date Completed	Letter Grade Earned
BIOL 2113*
BIOL 2113L*
BIOL 2114*
BIOL 2114L*
ENGL 1101
MATH 1111 OR
MATH 1101
CHEM1211* AND
CHEM 1211L* OR
CHEM 1151* AND
CHEM 1151L*

*Course must be completed within the seven years of the program cohort start date.

I understand that this request, along with all course information and supporting transcripts, must be received by the application deadline. I also understand that completion of these courses and meeting other minimum requirements does not guarantee selection as there are a limited number of seats available in the occupational and clinical courses.

Signature*

Clear

Date*

Date

Select a campus*

Murphy

The Medical Assisting program requires the following courses to be completed by the application deadline. Each course must be completed with a minimum grade of C. In addition to earning a minimum grade of C in each course, an overall GPA of 2.5 must be earned in the required courses. Specific technical, science, and Health Science courses must be completed within seven years of the start of the program cohort start date.

Please identify where and when each course was completed, and the letter grade attained. If you repeated a required course, please list information relative to the highest grade achieved. WGTC must have an official transcript on file for each college previously attended. Please view your WGTC academic history through Self-Service BANNER Web to find the dates and grades for specific courses completed with WGTC.

Required Courses*

	College Where Completed	Date Completed	Letter Grade Earned
ALHS 1090*
ALHS 1011* - see ALHS 1011 alternatives below for alternate courses
ENGL 1010 OR
ENGL 1101
MATH 1012 OR
MATH 1101 OR
MATH 1111 OR
MATH 1113

*Course must be completed within the seven years of the program cohort start date.

ALHS 1011 Alternatives: In lieu of ALHS 1011, ALL FOUR of the following courses together may be taken as an alternative (all four must be taken with a minimum grade of C):

	College Where Completed	Date Completed	Letter Grade Earned
BIOL 2113*
BIOL2113L*
BIOL 2114*
BIOL 2114L*

In addition to the courses listed above, a student must complete COMP 1000 and PSYC 1010 prior to the program cohort start date. Although the courses are not required to be completed prior to the application deadline, they must be completed before the medical Assisting cohort begins.

Have you completed COMP 1000?*

YesNo

Have you completed PSYC 1010?*

YesNo

Are you currently enrolled in COMP 1000?*

YesNo

Are you currently enrolled in PSYC 1010?*

YesNo

If you have completed COMP 1000 and PSYC 1010, please list the college where enrolled, as well as the dates of completion. If you are currently enrolled in COMP 1000 and PSYC 1010, list the anticipated dates of completion.*

	College Where Completed	(Anticipated) Date of Completion	Letter Grade Earned
COMP 1000
PSYC 1010

*Course must be completed within the seven years of the program cohort start date.

Bonus points are available in the selection process. Please indicate (yes or no) if you are requesting additional points for any of the following. (Maximum three (2) bonus points available):

A. One (1) point for shadowing at a medical office for a minimum of four (4) hours If you are requesting a bonus point, an employer letter of verification must be attached. This letter must be on company letterhead and include the dates and time of the shadowing experience and the job title and brief description of the duties of the staff member being shadowed.*

YesNo

If yes, submit an employer letter below on company letterhead, include dates of employment, job title, and a brief description of duties for consideration*

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B. Two (2) points for current State Certified Nursing Assistant Certification (CNA) or Registered Phlebotomy Technician (RPT) If you are requesting bonus points, a copy of the certification or licensure must be attached. If the certification or licensure was obtained more than five (5) years ago, an employer letter of verification, verifying a minimum of one (1) year employment as a CNA or Phlebotomy Technician within the last five (5) years must be attached. This letter must be on company letterhead and include the dates of employment, job title, and a brief description of duties.*

YesNo

If yes, submit a copy of your certification or licensure

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I understand that this request, along with all course information and supporting transcripts, test results, and copy of current CPR card, must be received by the application deadline. I also understand that completion of these courses and meeting other minimum requirements does not guarantee selection as there are a limited number of seats available in the occupational and clinical courses, and selection is based on the competitive selection process.

Signature*

Clear

Date*

Date

Select a campus*

Douglas

Have you completed the Test of Essential Academic Skills (TEAS) exam with a minimum Adjusted Individual Total Score of 70%?*

YesNo

Have you completed the Psychological Services Bureau (PSB) Health Occupations Aptitude Examination with a minimum raw score of 200 between August 31,2021-August 31, 2022?*

YesNo

Upload a copy of your scores here:*

Browse Files

The Dental Hygiene program requires the following courses to be completed by the application deadline. Each course must be completed with a minimum grade of C. In addition to earning a minimum grade of C in each course, an overall GPA of 3.0 must be earned in the required courses. Specific technical, science, and Health Science courses must be completed within seven years of the start of the program cohort start date.

Please identify where and when each course was completed, and the letter grade attained. If you repeated a required course, please list information relative to the highest grade achieved. WGTC must have an official transcript on file for each college previously attended. Please view your WGTC academic history through Self-Service BANNER Web to find the dates and grades for specific courses completed with WGTC.

Required Courses*

	College Where Completed	Date Completed	Letter Grade Earned
BIOL 2113*
BIOL 2113L*
BIOL 2114*
BIOL 2114L*
ENGL 1101
MATH 1111 OR
MATH 1101

*Course must be completed within the seven years of the program cohort start date.

In addition to the courses listed above, a student must complete CHEM 1211 & CHEM 1211L or CHEM 1151 & CHEM 1151L, AND BIOL 2117 & BIOL 2117L with a minimum grade of C within seven years of the start of the program cohort. Although the courses are not required to be completed prior to the application deadline, they must be completed before the Dental Hygiene cohort begins.

Have you completed CHEM 1211 & CHEM 1211L?*

YesNo

Have you completed CHEM 1151 & CHEM 1151L?*

YesNo

Have you completed BIOL 2117 & BIOL 2117L?*

YesNo

Are you currently enrolled in CHEM 1211 & CHEM 1211L?*

YesNo

Are you currently enrolled in CHEM 1151 & CHEM 1151L?*

YesNo

Are you currently enrolled in BIOL 2117 & BIOL 2117L?*

YesNo

If you have completed CHEM 1211 & CHEM 1211L or CHEM 1151 & CHEM 1151L, AND BIOL 2117 & BIOL 2117L, please list the college where enrolled, as well as the dates of completion. If you are currently enrolled in the above classes, list the anticipated dates of completion.*

	College Where Completed	(Anticipated) Date of Completion	Letter Grade Earned
BIOL 2117*
BIOL 2117L*
CHEM1211* AND
CHEM 1211L* OR
CHEM 1151* AND
CHEM 1151L*

*Course must be completed within the seven years of the program cohort start date.

Bonus points are available in the selection process for students with previous work experience. Please indicate (yes or no) if you are requesting additional points for any of the following. (Maximum three (3) bonus points available):

A. One (1) point for any clinical work experience.*

YesNo

If yes, submit an employer letter below on company letterhead, include dates of employment, job title, and a brief description of duties for consideration

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B. Two (2) points for dental related work experience such as a lab technician or front office employee.*

YesNo

If yes, submit an employer letter below on company letterhead, include dates of employment, job title, and a brief description of duties for consideration

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C. Three (3) points for more than one year equivalent of full-time experience as a dental assistant.*

YesNo

If yes, submit an employer letter below on company letterhead, include dates of employment, job title, and a brief description of duties for consideration

Browse Files

I understand that this request, along with all course information and supporting transcripts, test results, and copy of current CPR card, must be received by the application deadline. I also understand that completion of these courses and meeting other minimum requirements does not guarantee selection as there are a limited number of seats available in the occupational and clinical courses, and selection is based on the competitive selection process.

Signature*

Clear

Date*

Date

Select a campus*

Douglas

Have you completed the Test of Essential Academic Skills (TEAS) exam with a minimum Adjusted Individual Total Score of 70%?*

YesNo

Have you completed the Psychological Services Bureau (PSB) Health Occupations Aptitude Examination with a minimum raw score of 200 between August 31, 2021-August 31, 2022?*

YesNo

Upload a copy of your scores here:*

Browse Files

The Radiologic Technology program requires the following courses to be completed by the application deadline. Each course must be completed with a minimum grade of C. In addition to earning a minimum grade of C in each course, an overall GPA of 3.0 must be earned in the required courses. Specific technical, science, and Health Science courses must be completed within seven years of the start of the program cohort start date.

Please identify where and when each course was completed, and the letter grade attained. If you repeated a required course, please list information relative to the highest grade achieved. WGTC must have an official transcript on file for each college previously attended. Please view your WGTC academic history through Self-Service BANNER Web to find the dates and grades for specific courses completed with WGTC.

Required Courses*

	College Where Completed	Date Completed	Letter Grade Earned
BIOL 2113*
BIOL 2113L*
BIOL 2114*
BIOL 2114L*
ENGL 1101
PSYC 1101
MATH 1111 OR
MATH 1101

*Course must be completed within the seven years of the program cohort start date.

The student must complete ALHS 1090 with a minimum grade of C within the seven years preceding the program cohort start date. Although the course is not required to be completed prior to the application deadline, it must be completed before the Radiologic Technology cohort begins.

Have you completed ALHS 1090 with a minimum grade of C?*

YesNo

Are you currently enrolled in ALHS 1090?*

YesNo

If you have completed ALHS 1090, please list the college where enrolled, as well as the dates of completion. If you are currently enrolled in ALHS 1090, list the anticipated dates of completion.*

	College Where Completed	(Anticipated) Date of Completion	Letter Grade Earned
ALHS 1090*

*Course must be completed within the seven years of the program cohort start date.

I understand that this request, along with all course information and supporting transcripts, test results, and copy of current CPR card, must be received by the application deadline. I also understand that completion of these courses and meeting other minimum requirements does not guarantee selection as there are a limited number of seats available in the occupational and clinical courses, and selection is based on the competitive selection process.

Signature*

Clear

Date*

Date

Select a campus*

Murphy

The Surgical Technology program requires the following courses to be completed by the application deadline. Each course must be completed with a minimum grade of C. In addition to earning a minimum grade of C in each course, an overall GPA of 3.0 must be earned in the required courses. Specific technical, science, and Health Science courses must be completed within seven years of the start of the program cohort start date.

Please identify where and when each course was completed, and the letter grade attained. If you repeated a required course, please list information relative to the highest grade achieved. WGTC must have an official transcript on file for each college previously attended. Please view your WGTC academic history through Self-Service BANNER Web to find the dates and grades for specific courses completed with WGTC.

Required Courses*

	College Where Completed	Date Completed	Letter Grade Earned
ALHS 1090*
BIOL 2113*
BIOL 2113L*
BIOL 2114*
BIOL 2114L*
ENGL 1101
PSYCH 1101
MATH 1111 OR
MATH 1103

*Course must be completed within the seven years of the program cohort start date.

Bonus points are available in the selection process. Please indicate (yes or no) if you are requesting additional points for any of the following. (Maximum three (3) bonus points available):

A. One (1) point for 6 months of clinical work experience. Clinical experience is defined as actual patient care that includes the delivery of physical care such as certified nursing assistant, nurse aide, licensed practical nurse, patient care technician, medical assistant, surgical technician, back office worker in a clinic or physician’s office, or emergency medical technician.*

YesNo

If yes, submit an employer letter below on company letterhead, include dates of employment, job title, and a brief description of duties for consideration*

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B. Two (2) points for six to twelve months Surgical work experience such as a surgical technician or surgical clerk.*

YesNo

If yes, submit an employer letter below on company letterhead, include dates of employment, job title, and a brief description of duties for consideration

Browse Files

C. Three (3) points for more than one year equivalent of full-time experience as a surgical technician.*

YesNo

If yes, submit an employer letter below on company letterhead, include dates of employment, job title, and a brief description of duties for consideration

Browse Files

I understand that this request, along with all course information and supporting transcripts, test results, and copy of current CPR card, must be received by the application deadline. I also understand that completion of these courses and meeting other minimum requirements does not guarantee selection as there are a limited number of seats available in the occupational and clinical courses, and selection is based on the competitive selection process.

Signature*

Clear

Date*

Date

As set forth in its student catalog, West Georgia Technical College does not discriminate on the basis of race, color, creed, national or ethnic origin, sex, age, religion, disability, political affiliation or belief, genetic information, disabled veteran, a veteran of the Vietnam Era, or citizenship status (except in those special circumstances permitted or mandated by law). The following persons have been designated to handle inquiries regarding the non-discrimination policies: Equity (Title IX) Coordinator, Dean of Students, 770.537.5722, 176 Murphy Campus Blvd., Waco, GA 30182. ADA (Section 504) coordinator is Executive V.P. of Administrative Services, 678.664.0533, 401 Adamson Square, Carrollton, GA 30117.

Competitive Selection File Review Request Form

Registered Nursing

Practical Nursing to Registered Nursing Bridge

Practical Nursing

Medical Laboratory Technology

Medical Assisting

Dental Hygiene

Radiologic Technology

Surgical Technology