Please check the class you are applying for: Spring MARCH 2025 Full-Time class Summer May 2025 part-time Class Fall September 2025 Full-Time class Your name First name MI Last name Other name If your name has been changed, please provide your name as it may appear on other records. Birth Date Sex Male Female Are you a resident of Pennsylvania? YES (MORE THAN TWO YEARS) YES (LESS THAN TWO YEARS) NO Your Contact Information Email Confirm email Phone Number Current Legal Residence: Street address P.O. Box or apartment number City State ZIP code If you are under the age of 21, please identify your emergency contact. Relationship to you: Father Mother Guardian Spouse Other… Enter other… Emergency contact information Name Phone Number Address Address City/Town State ZIP/Postal Code Please complete this information in accordance with federal and state reporting requirements. Information will be kept confidential. Race? American Indian/Alaskan Native A person having origins in any of the Original Peoples of North American and who maintains cultural identification through tribal affiliation or community recognition. Asian/Pacific Islander A person having origins in any of the original peoples of the Far East, Southeast Asia, the Indian subcontinent or Pacific Islands. This includes peoples from China, Japan, Korea, the Philippine Islands, Samoa, India. and Vietnam. Black (Non-Hispanic) A person having origins in any of the black racial groups of Africa (except those of Hispanic origin). Hispanic A person of Mexican, Puerto Rican, Cuban, Central or South American or other Spanish culture or origin, regardless of race. White (Non-Hispanic) A person having origin in any of the original peoples of Europe, North Africa or the Middle East (except those of Hispanic origin). Tell Us About You? Education I am a Senior/12th grade. I am a high school graduate. I have earned a high school equivalency diploma (GED – attach a copy). I have taken college courses and earned college credits (attach official transcripts). I am a Certified Nurse’s Aide (CNA), EMT and/or Medical Office Assistant (include a letter of recommendation from your employer on facility letterhead with a copy of your certification). I expect to graduate in Month/year of GED exam Currently Employed? Yes No Where: Citizenship I am a U.S. citizen. I am a permanent resident but not a U.S. citizen. I am a nonresident alien. A person who is a citizen or national of the United States who is in this country on a visa or temporary basis and does not have the right to remain indefinitely. Years lived in PA List type of visa Home Country Languages English is my native language. I speak another language. I have taken the Test of English as a foreign language (TOEFL). Languages TOEFL Exam date Total TOEFL Score Will you be applying for Veterans Benefits? Yes No If yes, which benefits? National Guards/Reserves Active Duty GI Bill VA Rehab Dependent Please list your significant personal achievements: Personal achievements for example: participation in organizations, activities, sports, and community service, work experience as well as special awards you have earned. High School & College Experience High School City, State Major Year of Graduation Or last semester attended Degree Diploma/GED Vo-Tech, Career Center, AVTS, etc City, State Major Year of Graduation Or last semester attended Degree College or University City, State Major Year of Graduation Or last semester attended Degree None/Certificate/Associate/Bachelor/Masters/Doctorate Documents Upload documents as requested below. If documents cannot be uploaded here, you may email them to Wendy Joachim at wlj2@pct.edu or mail them to Penn College at Wellsboro, 22 Walnut St., Wellsboro, PA 16901. High School transcript / GED score Upload your transcript or ask your high school principal or guidance counselor to send your official high school transcript to Penn College at Wellsboro. If you have a Pennsylvania GED, submit your official score. If you do not have a PA GED, Please call us at 570-724-7703 or email to wlj2@pct.edu.One file only.100 MB limit.Allowed types: pdf, doc, docx, jpg, jpeg, png. Official college transcripts Have your official college transcripts sent directly to Penn College at Wellsboro. If you pick them up, they must be delivered to us in an envelope SEALED directly from the college.One file only.100 MB limit.Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods. Copy of certification Submit any other certifications or courses you have completed: CNA, MA, paramedic, EMT, or PCT.Unlimited number of files can be uploaded to this field.100 MB limit.Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods. Letters of reference Letter of recommendation 1 One file only.100 MB limit.Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods. Letter of recommendation 2 One file only.100 MB limit.Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods. Submit two (2) letters of reference to Penn College at Wellsboro with writer’s name, address, and telephone number. If you currently work in the healthcare field, submit a letter of recommendation from your current employer/supervisor on facility letterhead and include a copy of your certification. Signature Please Sign Here Date I certify that all information provided is complete and accurate. Leave this field blank