Poplar Bluff Technical Career Center Enrichment Programs Application (adult students only)
3203 Oak Grove Road
Poplar Bluff, MO 63901
573-785-2248 573-785-4168 (fax)
573-785-6683 School of Cosmetology
573-785-7751 Mules Café Extension Campus -
1110 N Westwood Blvd, Poplar Bluff, Missouri 63901

Once you have completed your online application submission you will be responsible for bringing the appropriate deposit and necessary documents listed below to the Poplar Bluff Technical Career Center's main office. The program fee covers the cost of admission examinations and background check. Applications are not processed or considered complete until the deposit is received. Completion of this application does not constitute admission to the program of study for which the applicant is applying. The following documents will need to be submitted with your application:

*Official (Sealed) High School Transcript or GED/HiSet scores
*Copy of Proof of Immunizations Record
*Copy of Birth Certificate
*Copy of Drivers License
*Copy of Social Security Card
*Copy of a Proof of Residency (Official mail sent to your home address or address listed on application, i.e. utility bill, phone bill, etc)
*Copy of Marriage License (If it applies)
Email address *
Perspective Students
Prospective students should review admission procedures in the PBTCC School Catalog, which has information about instructional programs, the admission and financial aid processes, and the Poplar Bluff Technical Career Center in general. Completed applications should be submitted to the PBTCC main office at 3203 Oak Grove Road, Poplar Bluff, MO 63901, prior to deadlines. Incomplete applications will not be considered for admission to enrichment programs.
Failure to complete admission requirements by specific program cutoff dates may result in non-consideration for admission. No student will be considered as officially enrolled until all admission requirements are met.
The number of students enrolled in specific programs is limited to the number of available openings and/or a pre-set number of allowable students per program of study. Students applying to PBTCC programs are accepted according to the approved selection process as outlined in each program’s section. PBTCC programs are clock hour non-continuous enrollment. No student will be admitted to or allowed to begin a program five days after the first scheduled class.
Upon approval for admission, the student will receive a letter of acceptance with instructions regarding the next steps in the process to secure enrollment. It is vital these instructions are followed in the prescribed timeframe. Failure to do so may forfeit the student’s enrollment in the program. For further information contact the specific program coordinator or the Adult Education Coordinator.

Please visit us at 3203 Oak Grove Road during office hours (8:00 a.m. to 4:00 p.m.) or call 573-785-2248 for more information or for a paper application.

Charles W. Kinsey – Director

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Part 1 Personal Information
Social Security Number *
Your answer
Last Name *
Your answer
First name *
Your answer
Middle name *
Your answer
Maiden/Alias (Type "None" if this does not apply to you) *
Your answer
Address *
Your answer
Telephone - Home *
Your answer
Telephone - Cell
Your answer
Telephone - Business
Your answer
Email (must be a valid email) *
Your answer
Date of Birth *
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Does student use language other than English? If so, what language: *
Part 2 Program Choice (clearly indicate the desired program of study)
Program Choice *
If Other was selected list program name
Your answer
Part 3 Emergency Information
In Case of Emergency, Please Notify (name) *
Your answer
Emergency Contact Relationship to student *
Your answer
Emergency Contact Address *
Your answer
Emergency Contact Home/Cell Phone *
Your answer
Emergency Contact Work Phone
Your answer
List any medical conditions PBTCC staff should be aware of: *
Your answer
By electronically signing this I authorize Poplar Bluff Technical Career Center and Poplar Bluff R-1 Schools staff to use their discretion regarding emergency procedures. *
Your answer
Part 4 Student Status Information
(the following information is optional)
Gender *
Martial Status *
Ethnic Description *
I have received a bachelor's degree *
I am eligible and will receive funding for the following agency to pay education expenses: *
List the name, address and social security number of the person eligible to claim the tax credits associated with the payment of tuition and related fees: (only applicable if other than student applying)
Your answer
Part 5 Education Information and Work Experience
Name of High School (City and State) *
Your answer
Graduation (year) or will Graduate (year) approximation is acceptable *
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GED/HiSet (Year)
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GED/HiSet Certificate Number
Your answer
Transcript Information
Official high school transcript or GED/HiSet scores must be forwarded to PBTCC to fully complete admission process.

Other Education Beyond High School – Official post-secondary school transcript must be forwarded to PBTCC to fully complete admission process.
Name of Post Secondary School/Schools Attended (City and State) (Degree/Certificate Earned) (Dates of Attendance)
Your answer
Have you ever experienced disciplinary or academic probation while attending a postsecondary institution of learning? If yes, please give a detailed explanation.
Your answer
List work experiences related to your field of study. Include experiences you feel are of benefit to you in your chosen field of study. (Employer, Position/Job Title, Year/Months Job Held)
Your answer
Part 6 Background information (required of all students to complete this component)
The Poplar Bluff Technical Career Center is an Equal Opportunity Employer and operates educational programs which do not discriminate on the basis of age, race, color, creed, religion, nationality origin, sex, marital status or handicap. The School district is prohibited from discriminatory practices by Title VI and Title VII of the Civil Rights Act of 1964, Title IX of the Education Amendments of 1972, section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act, Title II of Americans with Disabilities Act of 1990 and various state laws and regulations.
Have you ever been arrested and/or convicted of a felony or misdemeanor? *
If yes, on previous question it is required to explain.
Your answer
My digital signature below gives the Poplar Bluff Technical Career Center permission to perform a background check. I understand that my Social Security number and other personal data provided on this enrollment application may be used as an identifier. I further understand that the misrepresentation or omission of facts called for is cause for non admittance or dismissal from a Poplar Bluff Technical Career Center program of study. *
Your answer
Part 7 Functional Abilities Statement
The Poplar Bluff Technical Career Center programs require certain functional abilities a student must be able to do, possess, or be able to be taught in order to successfully complete the programs of study and perform in the chosen career fields. Refer to admissions section in the student catalog for the list of functional abilities required of students admitted into these programs.
By digitally signing this, I certify that I am physically and mentally able to perform the usual duties and functions associated with those of a nurse or cosmetologist and/or that I possess the capability to learn functional abilities as listed in student catalog in order to fulfill program requirements. *
Your answer
Completed Application Check Sheet (Bring all listed items as soon as possible after submitting an application to ensure priority processing):
• Official (Sealed) High School Diploma or GED/HiSet
• Proof of Immunizations
• Birth Certificate
• Driver’s License
• Social Security Card
• Proof of Residency (Official mail at your address or address listed on application, i.e. utility bill, cell phone bill, etc.)
• Marriage License & Divorce Determination (Cosmetology)
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