<p> Department of Allied Health PO Box 680 Silver City New Mexico 88062 Phone 575-538-6442 www.wnmu.edu Fax 575-538-6126</p><p>Occupational Therapy Assistant Application</p><p>Please print clearly or type:</p><p>Date______</p><p>Return to the address above or leave at the department office located in Room 131, Phelps Dodge. Application is due May 15th.</p><p>Name______</p><p>Current Mailing Address ______Street or PO Box City State Zip</p><p>Permanent Mailing Address______Street or PO Box City State Zip</p><p>Phone______Email ______Home Work Permanent</p><p>Ethnicity (optional): White/Non Hispanic ( ) Black/Non Hispanic ( ) Hispanic ( ) Asian ( ) American Indian or Alaskan Native ( ) </p><p>Do you have any disabling condition, which requires accommodation? ( ) Yes ( ) No</p><p>If “yes,” please describe your disability: ______</p><p>Compass score for reading ______Compass score for writing ______(Supporting documentation required). </p><p>Compass scores not required if you have completed English 101 with a C or better (Supporting documentation or transcript from an accredited university required).</p><p>Prerequisites List course, grade received, date of completion, and school where class was taken. Prerequisites must have been completed within the last five years. (Transcript from appropriate school required.)</p><p>Biology Anatomy & Physiology I ______course grade/year school</p><p>Bology Anatomy & Physiology II ______course grade/year school</p><p>Algebra ______course grade/year school Previous Education List all colleges or universities you have attended (transcripts required). College or University Dates of Number of credit hours attendance completed and GPA</p><p>Work Experience Resume may be substituted for this section. You may attach additional pages. Employer Position/duties Dates of employment</p><p>Volunteer Experience You may attach additional pages if required. Facility Area of service/duties Dates of service</p><p>References List three professional references we may call and INCLUDE THREE LETTERS OF REFERENCES (can be the same people listed here). Be sure phone numbers are current. If we are unable to contact these persons due to inaccurate information, points for your application will not be accrued.</p><p>Name Telephone Relationship & years known</p><p>Honors/Affiliations List any honors, awards, professional recognition, professional certificates, etc. you have received.</p><p>*Incomplete applications will not be accepted. </p><p>ESSAYS – Please compose two essays in response to the following topics/questions on a separate sheet of paper. Submit essays with application. 1. Please describe any experience you have working with, spending time with, or living with individuals with disabilities. If you have no experience, summarize your thoughts on what it might be like to actually have and live with a disability.</p><p>2. In choosing a career, how and why did you choose occupational therapy?</p>