FALL 2027

Blinn College Dental Hygiene Program
Application

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:(h)() 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 (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.

School Name	Credit Hours	Degree / Certificate	Date Awarded or Expected

12.

Are you eligible to return to each of these institutions? YesNo

If no, please explain:

13.

Have you previously attended any health related programs? YesNo

If yes, complete the following information:

School Name:

Address:

Dates of Attendance: Graduated:YesNo Date:

Type of Program:

Section B – Work Experience

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.

Employer/Military Experience	Phone	Dates	Job Title
		to
		to
		to

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, 2026-Jan. 31, 2027:

Section C – Professionalism

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.

OBSERVATION HOURS: Enclose in your application packet the signed Observation Log.

Section D – Testing

19.

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.

20.

TSI / TSIA: Verify that you are ‘College Ready’ or ‘Exempt’ for all portions of the TSI. Applicants who have not completed the college assessments will be disqualified.

(initial) I am TSI/TSIA complete.

Section E – Courses and Continuing Education Form

21.

TRANSCRIPTS: Enclose official, unopened transcripts from all education 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 2021)
Microbiology must have been completed within the past 3 years. (no earlier than Fall 2023)

Gen. Academic courses required for dental hygiene degree	Grade (A-F) * if Repeated OR IP = In Progress NT = Not Taken	Semester Completed	College/University Location where completed	Your Course Equivalent (if not exact course listed)
CHEM 1405 or CHEM 1411 or CHEM 1305 w/1105 Intro. To Chemistry
BIOL 2401 A & P I
BIOL 2402 A & P II
BIOL 2420 or 2421 Microbiology
ENG 1301 Comp. & Rhetoric
SPCH 1311 or 1315 or 1321 Speech
SOCI 2326 or PSYC 2319 or SOCI 1301 w/ PSYC 2301 Social Psychology
PHIL 2306 Intro to Ethics

Section F – Miscellaneous

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. http://www.tsbde.texas.gov/licensing/criminal-history-evaluation/

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

NOTE

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 http://tsbde.texas.gov/licensing/criminal-history-evaluation/

22.

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.

Signature

Date

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.

Blinn College

Dental Hygiene Program Recommendation Form

Name of Applicant

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.

Applicant Signature

Date

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 have known the applicant in the following capacity and location:

I have known the applicant foryearsmonths.

I would evaluate the applicant as follows:

	EXCELLENT	ABOVE AVERAGE	AVERAGE	BELOW AVERAGE	NOT KNOWN
Attitudes toward others (caring, respect)
Ability to work with others
Ability to communicate orally
Ability to communicate in writing
Independence
Initiative
Ability to accept responsibility
Presentation of self (poise, courtesy, language)
Potential for growth

RECOMMENDATION:

Strongly RecommendRecommendRecommend with ReservationNot Recommend

Comment(s):

Signature

Date

Position

Address

Telephone

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

Blinn College

Dental Hygiene Program Recommendation Form

Name of Applicant

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.

Applicant Signature

Date

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 have known the applicant in the following capacity:

I have known the applicant formonthsyears.

I would evaluate the applicant as follows:

	EXCELLENT	ABOVE AVERAGE	AVERAGE	BELOW AVERAGE	NOT KNOWN
Attitudes toward others (caring, respect)
Ability to work with others
Ability to communicate orally
Ability to communicate in writing
Independence
Initiative
Ability to accept responsibility
Presentation of self (poise, courtesy, language)
Potential for growth

RECOMMENDATION:

Strongly RecommendRecommendRecommend with ReservationNot Recommend

Comment(s):

Signature

Date

Position

Address

Telephone

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

Blinn College

Dental Hygiene Program Recommendation Form

Name of Applicant

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.

Applicant Signature

Date

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 have known the applicant in the following capacity:

I have known the applicant formonthsyears.

I would evaluate the applicant as follows:

	EXCELLENT	ABOVE AVERAGE	AVERAGE	BELOW AVERAGE	NOT KNOWN
Attitudes toward others (caring, respect)
Ability to work with others
Ability to communicate orally
Ability to communicate in writing
Independence
Initiative
Ability to accept responsibility
Presentation of self (poise, courtesy, language)
Potential for growth

RECOMMENDATION:

Strongly RecommendRecommendRecommend with ReservationNot Recommend

Comment(s):

Signature

Date

Position

Address

Telephone

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