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2020 Associate in Applied Science Application
School of Career and Technical Studies
Department of Allied Health and Nursing
(RETURN PAGES 2 & 3 with the required attachments listed on the NEXT PAGE)
Last Name: First Name: Middle Name:
_________________________ ______________________ __________________
Address: _____________________________________________________________________
City: ____________________ County: _______________ State: _________ Zip: __________
Telephone Numbers: Home: ______________ Work: _____________ Cell: ______________
Southern ID: ______________________ (If you do not have a Southern ID number, you
MUST ALSO APPLY for admission to Southern)
E-mail Address (MANDATORY): ________________________________________________
Are you a U. S. Citizen? Yes ☐ No ☐ Under Immigration and Naturalization Service’s rules, Southern
is
not an institution certified to receive international students.
Are you a Veteran? Yes ☐ No ☐
Are you currently enrolled as a Health Care Professional major student? Yes ☐ No ☐
You will only be considered for admission to the program(s) for which you apply. Please clarify
the program(s) of choice in numerical order. (ex. 1
st
, 2
nd
, 3
rd
, etc.)
_____ Medical Assisting – Boone Campus
_____ Medical Assisting – Williamson Campus
_____ Medical Laboratory Technology – Logan Campus
_____ Nursing – Logan Campus
_____ Paramedic Science – Logan Campus – (Pre-requisite – EMT-B)
_____ Radiologic Technology – Logan Campus
_____ Respiratory Care Technology – Williamson Campus
_____ Respiratory Care Technology – Wyoming Campus
_____ Surgical Technology – Logan Campus
*Failure to fully complete this application, provide truthful information, and/or send
required documentation will result in immediate ineligibility.
I certify that all information provided in connection with this application is true and correct to the
best of my knowledge. I understand that any misrepresentation or omission on this application
will result in immediate ineligibility from all Healthcare programs. I have applied for admission
to Southern West Virginia Community and Technical College and all transcripts are attached to
this application. I have also attached a copy of my ATI TEAS and/or ACT/SAT scores, if
applicable, to this application. By signing below I verify and hereby affirm that I have read and
understand this application.
________________________________________ ____________________________
Signature of Applicant Date
