Competitive Selection File Review Request Form

Name *

First Name Last Name

Student ID *

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number *

Area Code Phone Number

WGTC Email Address *

example@student.westgatech.edu

Which competitive selection program are you applying for? *

Registered Nursing Practical Nursing Clinical Laboratory Technology Medical Assisting Dental Hygiene Radiologic Technology Surgical Technology

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

In-State Reciprocity (residents of Chambers, Cleburne and Randolph counties in Alabama) Military Out of State Military/GA Domicile Other

Are you in good academic standing with WGTC? *

Yes No

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

Yes No Not applicable

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

Yes No

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 - June 1 application deadline Coweta - February 1 application deadline LaGrange - September 1 application deadline

Have you completed the Test of Essential Academic Skills (TEAS) exam with a minimum 75% Adjusted Individual Total Score? *

Yes No

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? *

Yes No

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

Date

Are you a current Licensed Practical Nurse? *

Yes No

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? *

Yes No Not 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? *

Yes No

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

Yes No

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. *

Yes No

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 *

Yes No

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

Yes No

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 Murphy LaGrange

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

Yes No

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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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 Clinical 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

Have you completed the Psychological Services Bureau (PSB) Health Occupations Aptitude Examination with a minimum raw score of 150? *

Yes No

Upload a copy of your scores here: *

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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 CISM 2201 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 CISM 2201? *

Yes No

Have you completed PSYC 1010? *

Yes No

Are you currently enrolled in CISM 2201? *

Yes No

Are you currently enrolled in PSYC 1010? *

Yes No

If you have completed CISM 2201 and PSYC 1010, please list the college where enrolled, as well as the dates of completion. If you are currently enrolled in CISM 2201 and PSYC 1010, list the anticipated dates of completion. *

College Where Completed

(Anticipated) Date of Completion

Letter Grade Earned

CISM 2201

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. *

Yes No

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. *

Yes No

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 Psychological Services Bureau (PSB) Health Occupations Aptitude Examination with a minimum raw score of 200? *

Yes No

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? *

Yes No

Have you completed CHEM 1151 & CHEM 1151L? *

Yes No

Have you completed BIOL 2117 & BIOL 2117L? *

Yes No

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

Yes No

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

Yes No

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

Yes No

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. *

Yes No

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. *

Yes No

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. *

Yes No

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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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 Psychological Services Bureau (PSB) Health Occupations Aptitude Examination with a minimum raw score of 200? *

Yes No

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? *

Yes No

Are you currently enrolled in ALHS 1090? *

Yes No

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

Have you completed the Psychological Services Bureau (PSB) Health Occupations Aptitude Examination with a minimum raw score of 200? *

Yes No

Upload a copy of your scores here: *

Browse Files

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. *

Yes No

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. *

Yes No

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 surgical technician. *

Yes No

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