Blinn College Dental Hygiene Program Application

Fall 2026

Print and complete this form to include in your application packet.

Section A - General Information

1. Date

2. DOB (month/day only)

Blinn College ID #

3. Full Name (Last, First, MI)

4. Other names under which credentials may be received

5. Permanent Address (Number and Street, City, State, Zip)

6. Mailing Address (Number and Street, City, State, Zip)

7. Telephone Number (home / cell)

8. E-mail Address you use

9. Emergency Contact (name / number)

10. Are you a citizen or permanent resident of the United States?
Yes No

11. List all educational institutions attended (colleges, universities, and professional schools) in order of attendance.

School Name	Credit Hours	Degree / Certificate	Date Awarded or Expected

12. Are you eligible to return to each of these institutions?
Yes No

If no, please explain

13. Have you previously attended any health related programs?
Yes No

If yes, Date

School Name

Address

Dates of Attendance

Graduated
Yes No

Type of Program

Section B - Employment & Community Service

14. Employment / Military Service
Beginning with the most recent, list years of employment and/or military service.

Employer / Military Experience	Phone	Dates	Job Title

Total number of years/months of employment and/or military service

15. Community Service
Total hours spent in community service activities from Feb. 1, 2025 - Jan. 31, 2026:

Section C - Professionalism

16. Recommendation Forms
Three completed recommendation forms must be received in sealed envelopes and enclosed in your application packet.

17. Professional Certifications
Enclose a copy of any current professional certifications you may have.

Section D - Testing

18. ATI-TEAS
Enclose your Individual Performance Profile score sheet in your application packet.

19. TSI / TSIA
Verify that you have completed or are exempt for all portions of the TSI.

Initial
I am TSI/TSIA complete.

Section E - Observation Log

19. Observation Hours
Enclose the signed Observation Log in your application packet.

Section F - Courses and Continuing Education Form

Complete the following table for required courses within the dental hygiene curriculum.

Required Course	Grade	Semester Completed	College / University	Equivalent Course (if applicable)
CHEM 1405 or CHEM 1411 or CHEM 1305 w/1105
BIOL 2401 - A&P I
BIOL 2402 - A&P II
BIOL 2420 or 2421 - Microbiology
ENGL 1301 - Comp. & Rhetoric
SPCH 1311 / 1315 / 1321 - Speech
SOCI 2326 or PSYC 2319 or SOCI 1301 w/PSYC 2301
PHIL 2306 - Intro to Ethics

Section G - Miscellaneous

20. Transcripts
Enclose official, unopened transcripts from all educational institutions attended.

Initial
I have enclosed official transcripts from all colleges I attended.

22. Background Checks
I acknowledge that a criminal background check and drug and alcohol screenings will be required for all applicants who are offered a position.

Initial

Important: If you have been convicted of a misdemeanor or felony, it is suggested that you complete a Criminal History Evaluation (CHE) from the Texas State Board of Dental Examiners to ensure licensure eligibility upon graduation from the program.

Applicant Signature

I certify that the information provided in this application is correct and complete. I understand that omission or falsification of information is grounds for exclusion or dismissal. If accepted into the program, I agree to meet all entrance requirements and to abide by the rules, regulations, and procedures of Blinn College and this program. I understand that I will be subject to a criminal background check and drug testing prior to beginning the program, if accepted. I have received a copy of and read the Application Procedures Guide and the Communicable Disease policy statement.

Signature

Date