Admission Application - Mammography

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Program:

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Program:*

Mammography (Advanced Program)

Personal Information:

Last Name:*

First name:*

Middle Name:

Maiden Name:

Citizenship:

American Registry of Radiologic Technologists #:

Optional

The following three fields are OPTIONAL and are used for financial aid and student healthcare purposes only.

Date of Birth:

Place of Birth:

Gender:

Male

Female

Mailing Address:

Mailing Address*

Street Address City State ZIP Code

Permanent Address:

Permanent Address

Same as Mailing Address

Street Address City State / Province / Region ZIP / Postal Code Country

Home Phone*

Cell Phone

E-mail Address:*

Emergency Contact Information:

Emergency Contact:

Relationship:

Address

Street Address City State ZIP Code

Phone

Education:

Radiologic Technology

Name/Location

Attended From

Attended To

Graduated

Degree/Diploma

If course was not completed, state reason:

How were you informed about the school for which you are applying?

Date of ARRT or other U.S. Certification Exam (if applicable):

Status:

Anticipated

Completed

Employment:

List previous employers, starting with the last employer, including dates employed.

Employer #1

Name/Address

Business

Employed From

MM/YY

Employed To

MM/YY

Position

Reason for Leaving

Employer #2

Name/Address

Business

Employed From

MM/YY

Employed To

MM/YY

Position

Reason for Leaving

References:

List four (4) references who have supervised the applicant a minimum of six months in an evaluating position (such as supervisors, educators, etc.). Friends, relatives, clergy and co-workers are not acceptable references. References for Radiation Therapy must include at least two (2) allied health program faculty members, if applicable.

Reference #1:

Reference Name:

Email Address:

Position/Title:

Address:

City:

State:

ZIP/Postal Code:

Reference #2:

Reference Name:

Email Address:

Position/Title:

Address:

City:

State:

ZIP/Postal Code:

Reference #3:

Reference Name:

Email Address:

Position/Title:

Address:

City:

State:

ZIP/Postal Code:

Reference #4:

Reference Name:

Email Address:

Position/Title:

Address:

City:

State:

ZIP/Postal Code:

Miscellaneous:

Has your ARRT license ever been suspended, revoked or placed on probation? If yes, please state reason.

Yes

No

If yes, please state reason.

Have you ever made application to this program before?

Yes

No

If Yes, what year?

Have you ever been convicted of a felony or misdemeanor (other than traffic violations)?

Yes

No

If Yes, explain what type of conviction:

Autobiographical Sketch:

In the space provided below, please type a brief autobiography (minimum 500 words). Include your personal history, family background, secondary and collegiate education, reasons for selecting this career, work experiences in the health field, why you are interested in applying for admission to Grady Health System, and other statements that would indicate your attitude, motivation, and interest in this profession.

Application Instructions:

All application portfolio documents must be postmarked by April 1/October 15. Portfolio documents includes: the Application, Application Fee, Brief Autobiography, Professional References, Documentation of Current ARRT Certification or Eligibility. Incomplete applications will not be considered for admission to the program. All documents are mailed to:

Admissions Office
Radiation and Imaging Technologies
Grady Health System
80 Jesse Hill Jr. Drive, SE – Box 26095
Atlanta, GA 30303-3050

Application Fee:

Non Refundable

Price:

Credit Card*

Confirm

The information submitted on this application is true to the best of my knowledge. I understand that making false statements, submitting an incomplete application portfolio, and/or not adhering to procedures and/or deadline dates will render my application disqualified. Permission is granted to contact references.

Yes

No

CAPTCHA

Name

This field is for validation purposes and should be left unchanged.

Admission ApplicationMammography

Program:

Personal Information:

Optional

Mailing Address:

Permanent Address:

Emergency Contact Information:

Education:

Radiologic Technology

Employment:

Employer #1

Employer #2

References:

Reference #1:

Reference #2:

Reference #3:

Reference #4:

Miscellaneous:

Application Instructions:

Admission Application
Mammography