Mississippi School of Health Services & Careers Application Form

Full Name

The goal of this College is to ensure students complete their coursework in a timely effort, pass all licensure exams and provide a career path that ensures their success in the students' chosen career.

The payment of the admission application fee of $50 (non-refundable) must be paid before your application is considered complete and you can register for classes.

Please call us at 769-572-7490 or come by the campus to pay your application fee.

Thank you again for your patience and your commitment to the College of Health Services and Careers.

Marcus A. Chanay, Ph.D., CFRM President

Birth Date

Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number

Area CodePhone Number

E-mail

Gender

Program(s) of Study interested in

High School

High School Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Attended from

Did you Graduate?

Diploma

College

College Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Attended from

Did you Graduate?

Have you ever been convicted of a felony?

If yes, please explain.

Degree / Program of Study

Other

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Attended from

Did you Graduate?

Degree / Program of Study

I will be attending the MS School of Health Services and Careers

Other

I will be entering the following program

What specialty to you plan to pursue after completion?

Whare are your educations & professional goals & objectives?

Signature of Scholarship Applicant