9. List your employment experiences over the past 10 years, including military service. Add additional sheet if necessary.
1. ________________________________________________________________________FROM_______TO_______ ________________________
2. ________________________________________________________________________FROM_______TO_______ ________________________
3. ________________________________________________________________________FROM_______TO_______ ________________________
10. Are you reapplying for this program? Yes_____ No _____. If yes, when did you last apply?__________________________________________________
11. Are you a veteran of the US Military Service? Yes _____ No _____. If YES, are you eligible for and certified by the Veterans Administration for education
benefits? Yes _____ No _____ If YES, attach page to this application and give branch of service, dates entered and separated from service, rank at time of
separation and type of discharge.
12. Are you a member of the National Guard or Reserve? Yes_____ No _____. If YES, attach page to application and give branch, days and number of meetings
attended each month.
13. Have you ever been suspended or dismissed from any college or university for scholastic or disciplinary reasons? Yes_____ No_____. If YES, give name of
institution, date and reason for this action. ___________________________________________________________________________________________
14. Have you applied for admission to other Allied Health Programs at Delgado? Yes_____ No_____. If YES, give the program name and dates.
15. Are you a U.S. Citizen? Yes_____ No _____.
16. Optional Response: If you have a disability, describe on a separate page any special equipment, architectural modifications, or other factors which would have to
be considered by you and by the School/department in planning your educational experience at Delgado Community College if you are accepted for admission.
ALL APPLICANTS PLEASE READ CAREFULLY AND SIGN THE FOLLOWING
Other than a minor traffic violation, have you ever been convicted of a felony? Yes_______ No _______ If yes, please explain on additional page.
NOTE: The National Certification Boards may refuse to grant Certification to persons who have been convicted of a felony.
I understand that the information submitted on this application for admission to Delgado Community College’s Allied Health
program in my name will be relied upon by Delgado Community College officials to determine my status for admission
eligibility. I authorize Delgado Community College officials to verify any information I have provided. I further authorize
any and all educational institutions, governmental agencies, and private employers that I have attended, worked for, or who
maintain records related to me to release such information to Delgado Community College.
I agree to notify Delgado Community College’s Allied Health Admissions Office of any changes to the information provided.
I certify that the information in this application is complete and correct and understand that submission of false, incomplete,
or incorrect information is grounds for rejection of my application, withdrawal of any acceptance offer, cancellation of
enrollment, or appropriate disciplinary action. I understand it is also necessary to conform to the program’s technical
standards and requirements concerning a physical examination. If accepted, I agree to abide by and observe all program and
affiliate hospital policies, rules and regulations, as amended from time to time.
I also understand that this application is for the Diagnostic Medical Sonography Program only. If accepted to Program, I
must apply for admission to Delgado Community College. Completion of this form does not indicate that you are accepted
into the program.
Signature of Applicant Date