Blinn College Dental Hygiene Program Application

9. Emergency Contact (name / number)

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

11. List all educational institutions (colleges, universities, and professional schools) in order of attendance. Do not omit the name of any institution where you have been a student. If necessary, use a separate sheet of paper.

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, complete the following information:

School Name, Address, Dates of Attendance, Graduated (Yes / No), Date, Type of Program

14. Employment - Beginning with the most recent, please list years of employment and/or military service. Enclose in application packet letters and/or signed statements from employers or DD-214, verifying up to 2 years of employment tenure / military status.

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

15. Community Service - Enclose Community Service Log or letters providing dates of activities on letterhead from a supervisor.

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

16. Recommendation Forms - Complete and sign the top portion of the forms, “Recommendation for Dental Hygiene”. Three (3) completed recommendation forms must be received in sealed envelopes and enclosed in your application packet. References may be validated by our office.

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

18. ATI-TEAS - Enclose your Individual Performance Profile score sheet in your application packet. Score sheet must have your name and date of test on it.

19. TSI / TSIA - Verify that you have completed or are exempt for all portions of the TSI. Applicants who have not completed the college assessments will be disqualified.

(initial) I am TSI / TSIA complete.

20. Observation Hours - Enclose in your application packet the signed Observation Log.

21. Transcripts - Enclose official, unopened transcripts from all educational institutions attended in your application packet. Missing transcripts may result in a denial of credit for classes completed and/or disqualification of your application. Transfer classes on another college's transcript are not accepted as official.

(initial) I have enclosed official transcripts from all colleges I attended.

22. Grades - Complete the following table for required courses within the dental hygiene curriculum:

A&P 2 must have been completed within the past 5 years (no earlier than Fall 2019). Microbiology must have been completed within the past 3 years (no earlier than Fall 2021).

23. Background Checks - A criminal background check and drug screening will be required for all applicants who are offered a position. Further information will be provided if you are accepted into the program.

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. Graduation from the program does not ensure eligibility to be licensed and practice dental hygiene in the state of Texas.

Texas State Board of Dental Examiners - Criminal History Evaluation

If interested in licensure in other states, please reference the individual states' dental boards for information.

Possible Board Exam / Employment Qualifiers

• Conviction of a felony or misdemeanor that relates to the duties and responsibilities of the licensed occupation.
• Dependence on alcohol, drugs, and other chemicals.
• Dismissal from employment due to unprofessional or dishonorable conduct.
• Restriction, suspension, revocation, or probation of licensure in another jurisdiction within the past 10 years.
• Failure to report disciplinary action received in another jurisdiction.

For further information, contact tsbde.texas.gov/licensing/criminal-history-evaluation.

24. 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 confirm and abide by the letter and the spirit of the rules, regulations, and procedures of Blinn College and this program. In addition, I am aware that I will be subject to a criminal background check and drug testing (cost to the applicant) prior to beginning the dental hygiene program, if accepted. I have received a copy and read the Application Procedures Guide and the Communicable Disease policy statement.

Is your application complete?

• Please use the enclosed checklist to ensure your application is complete.
• Submit in a 9x12 envelope.
• Have you contacted the Dental Hygiene Program for answers to your questions concerning this application? We are very happy to help you.
• Submit the Dental Hygiene Application and all correspondence to:

Blinn College
ATTN: Dental Hygiene Program
P.O. Box 6030
Bryan, TX 77805-6030

Or deliver to:
301 Post Office St.
Bryan, TX 77801

You are responsible for ensuring that all information has been received by the Blinn College Dental Hygiene Program. Any application that is not complete cannot be considered for entrance into the program.

References should be from teachers, employers, clergy, counselors, or commanding officers with whom the applicant has had professional relationships. References from family members or friends are not accepted. Submitting inappropriate references will result in fewer points than the maximum allows for this portion of the application process.

To assure that your records are held in compliance with the law as stated below, please check one:

I GIVE UP my right to access of this form.
I DO NOT GIVE UP my right to access of this form.

The above named applicant is a candidate for admission to the Blinn College Dental Hygiene Program and has named you as a reference. Your comments will be used only by the admissions committee of the dental hygiene program to assist them in arriving at a better understanding of this applicant. Your cooperation in completing this form will assist both the applicant and the Dental Hygiene Program.

* Please Note: FERPA grants a student / applicant access to his / her records as maintained by the department of Dental Hygiene at Blinn College. It also grants a student / applicant the right to waive access. See above for the student’s / applicant’s choice regarding confidentiality.

I would evaluate the applicant as follows:

Recommendation

Strongly Recommend
Recommend
Recommend with Reservation
Not Recommend

Comment(s)

Position

Address

Telephone

Please return this form to the applicant in a sealed envelope.

References should be from teachers, employers, clergy, counselors, or commanding officers with whom the applicant has had professional relationships. References from family members or friends are not accepted. Submitting inappropriate references will result in fewer points than the maximum allows for this portion of the application process.

To assure that your records are held in compliance with the law as stated below, please check one:

I GIVE UP my right to access of this form.
I DO NOT GIVE UP my right to access of this form.

The above named applicant is a candidate for admission to the Blinn College Dental Hygiene Program and has named you as a reference. Your comments will be used only by the admissions committee of the dental hygiene program to assist them in arriving at a better understanding of this applicant. Your cooperation in completing this form will assist both the applicant and the Dental Hygiene Program.

* Please Note: FERPA grants a student / applicant access to his / her records as maintained by the department of Dental Hygiene at Blinn College. It also grants a student / applicant the right to waive access. See above for the student’s / applicant’s choice regarding confidentiality.

I would evaluate the applicant as follows:

Recommendation

Strongly Recommend
Recommend
Recommend with Reservation
Not Recommend

Comment(s)

Position

Address

Telephone

Please return this form to the applicant in a sealed envelope.

References should be from teachers, employers, clergy, counselors, or commanding officers with whom the applicant has had professional relationships. References from family members or friends are not accepted. Submitting inappropriate references will result in fewer points than the maximum allows for this portion of the application process.

To assure that your records are held in compliance with the law as stated below, please check one:

I GIVE UP my right to access of this form.
I DO NOT GIVE UP my right to access of this form.

The above named applicant is a candidate for admission to the Blinn College Dental Hygiene Program and has named you as a reference. Your comments will be used only by the admissions committee of the dental hygiene program to assist them in arriving at a better understanding of this applicant. Your cooperation in completing this form will assist both the applicant and the Dental Hygiene Program.

* Please Note: FERPA grants a student / applicant access to his / her records as maintained by the department of Dental Hygiene at Blinn College. It also grants a student / applicant the right to waive access. See above for the student’s / applicant’s choice regarding confidentiality.

I would evaluate the applicant as follows:

Recommendation

Strongly Recommend
Recommend
Recommend with Reservation
Not Recommend

Comment(s)

Position

Address

Telephone

Please return this form to the applicant in a sealed envelope.