Application for Admission to the Medical Office Specialist Certificate Training Program

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Application Purpose and Guidelines:
The purpose of this application is to document the skill set of the Medical Office Specialist Certificate Training candidate. This enables the Selection Committee to properly assess each candidate’s skills, abilities, background and motivation to succeed. Our goal is to select candidates who will be successful in the program and become competitive for employment.

Submit the Completed application and supporting documents* to:

Great Bay Community College
Business & Training Center
320 Corporate Drive
Portsmouth, NH 03801

Required documentation:
1. High School Diploma, GED or HiSet
2. Resume
The Selection Committee will review the completed application and supporting documentation and interview the candidates. Interviews will be conducted when all required documentation has been received.

The selection process will consider:
- Candidates who are 18 years or older.
- Candidates who have a desire to work in the medical field
- Candidates who will commit to an intense twelve-week/240-hour program of instruction.
Application Information: MOS
Please indicate the class for which you are applying (start date):
Name*
First Middle Last
Address*
Street Address City State ZIP Code
Preferred Email*
Primary Phone*
Secondary Phone
- Cell
- Home
- Work
- Cell
- Home
- Work
Date of Birth
Date Format: MM slash DD slash YYYY
Are you a US Citizen/Permanent Resident?
- Yes
- No
Social Security #
Workforce Opportunity Act, a Federal grant, requires that we obtain information from students. The use of your social security number is requested in order to access wage and employment information through the state Unemployment Insurance wage information database. You cannot be denied service for failure to provide your social security number although we strongly encourage you to do so in order to enable the program to determine employment-related outcomes. Your personal information will be kept confidential and secure and will not be shared with any outside agencies other than New Hampshire Employment Security. By signed, you agree to participate in this initiative.
In a medical emergency, please contact:
Name*
First Last
Address*
Street Address City State ZIP Code
Phone*
Educational History
High School Last Attended:*
School Address*
Street Address City State ZIP Code
Year of High School Graduation*
Or Year G.E.D. / HiSet Awarded
Post-Secondary Education:
School Name
Address
City State ZIP Code
Year of Graduation
Or Dates of Attendance
Last Name While in High School (or GED/HiSet)
Employment History
1. Employer:*
Address:*
City State ZIP Code
Dates of Employment:*
Summary of Responsibilities:*
2. Employer:
Address:
City State ZIP Code
Dates of Employment:
Summary of Responsibilities:
Reference
Name*
First Last
Organization*
Relationship*
Address*
Street Address City State ZIP Code
Phone*
Email*
Signature of Applicant*
Date*
Date Format: MM slash DD slash YYYY
Notice of Non-Discrimination
Great Bay Community College does not discriminate in the administration of it admissions and educational programs, activities, or employment practices on the basis of race, color, religion, national origin, age, sex, disability, genetic information veteran status, sexual orientation, political affiliation or marital status. This statement is a reflection of the mission of the Community College System and Great Bay Community College and refers to, but is not limited to, the provisions of the following laws: Title VI and Title VII of the Civil Rights Act of 1964, as amended, the ~ The Age Discrimination Act of 1967 (ADEA) ~ Title IX of the Education Amendment of 1972 ~ Section 504 of the Rehabilitation Act of 1073 ~ The Americans with Disabilities Act of 1990 (ADA) ~ Section 402 of the Vietnam Era Veterans’ Readjustment Assistance Act of 1074 ~ Genetic Information Nondiscrimination Act of 2008.

Application Information: MOS

In a medical emergency, please contact:

Educational History

Post-Secondary Education:

Employment History

Reference