Addmissions Application Form

Admissions Application

Please complete the form below to apply for a position with us.
Full Name*

First NameMiddle NameLast Name
Current Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Email Address*
Phone Number

Area CodePhone Number
Applying for what class*
Start date

MonthDayYear
Upload Resume*

Upload a File

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Upload Drivers License/ID*

Upload a File

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Upload Ged/High School Diploma or Transcript/College Transcript*

Upload a File

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Highest Level of Education*
Graduation date

MonthDayYear
Date
Ged/High School/College Name*
Certificate/Diploma/Degree
I attest that I will provide a copy of my degree/transcript prior to graduation *
Signature*

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Employer Name*
Employer Status*
Start Date

MonthDayYear
Date
End Date (if not employed)

MonthDayYear
Date

Why should you be chosen to be a Student at the Buckhead School Of Medicine?*
Can you commit to 32-40 hours a week for school and clinicals?*
Can you arrive to class and clinicals on time?*
Can you keep patient records confidential according to the HIPAA policy?*
Do you have access to wifi or ethernet internet for online/distance education classes?*
Are you disciplined to participate online/distance education classes?*
Do you have a smartphone?*
Do you have a laptop or PC computer with camera and audio speakers?*
Do you give Buckhead School of Medicine Permission to post your social media feedback/post that you post on the schools website/google/yelp/social media platform ?*
Do you give Buckhead School to share post on all social media outlets ?*
Why do you want to be in the healthcare industry?*
Social Security Number*
Birth Date*

MonthDayYear
Date

Application Fee (Non Refunable Application Fee)*

USD1

Credit Card

Apple Pay

Google Pay

Cash App Pay

Admissions Application