Fillable Mammography Spring 2021 Program Application (Middlesex Community College)

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Mammography Spring 2021 Program Application (Middlesex Community College)

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Mammography
Spring 2021 Program Application
Middlesex Community College │Office of Enrollment Services
100 Training Hill Road │ Middletown CT 06457-4889
T 860.343.5719 │F 860.344.3055│www.mxcc.edu
Admission to the Mammography Program is selective and space is limited. This application does not guarantee acceptance.
The application deadline is November 6, 2020. Late applications and transcripts are not accepted.
APPLICANT’S LEGAL NAME (Last) (First) (Middle)
ARRT CERTIFICATION NUMBER
SOCIAL SECURITY NUMBER
BIRTH DATE (Month/Day/Year)
CURRENT MxCC STUDENT?
□ Yes □ No
ADDRESS (No. and Street) (Apt. #) (City or Town) (State) (Zip Code)
HOME TELEPHONE (Area Code)
CELL (Area Code)
Are you a United States Citizen?
□ Yes □ No □ Permanent Resident
COMMUNITY COLLEGE E-MAIL ADDRESS (all emails will be sent to your new community college email address. You can look up your new
email address in myCommNet)
PERSONAL E-MAIL ADDRESS
ACADEMIC REQUIREMENTS
Date Completed
Proof of High School Completion
Official copy of all college or university transcripts
If you have completed courses at Middlesex Community College, you do not need to submit a transcript from MXCC.
Copy of ARRT Certification
Copy of Current Radiographer License
SUPPLEMENTAL REQUIREMENTS
Complete Immunization Records
Application and supporting documents should be sent electronically (as a PDF) to lkatusha@mxcc.edu
For Office Use Only
Date
Banner
ID
Prerequisites Completed □ Yes □ No
Accepted into the Program □ Yes □ No
MxCC New Student Application
must also be on file.
ACADEMIC INFORMATION
College/University/Hospital attended for Radiologic Technology Program:
Semester of Completion:
Degree Earned:
What is the highest degree that you have earned (circle one): No degree
Associates Degree
Baccalaureate Degree
Master’s Degree
Doctoral Degree
List ALL Colleges or Universities attended. Failure to submit official transcripts from all previously attended
colleges & universities (including CT Community Colleges) by November 6, 2020 will make you ineligible for
the Spring 2021 academic semester.
Name of School & Address
(City, State & Country if outside the U.S.)
Dates Attended
Degrees/Certifications
Earned
1.
2.
3.
4.
5.
If you have attended additional colleges, please list them on a separate sheet of paper and submit along with
your application. Students who have attended or are currently attending one of the twelve Connecticut
Community Colleges must submit community college transcripts from all previously attended Connecticut
Community Colleges. There are no deadline extensions for applicants who fail to submit required
transcripts from the CT Community College System by the application deadline.
All transcripts must be final transcripts. You must submit all transcripts (including those with course
withdrawals, course failures, and remedial/developmental courses) regardless of the age of the transcripts
and applicability to the Mammography Program. This includes any college credits earned while in high school.
SUBMISSION OF APPLICATION
I have provided true, correct, and complete information. I have read and I understand the information
provided in the application instructions and the application packet. I understand that I must submit all official
supporting documents to the Middlesex Community College Office of Enrollment Services by November 6,
2020 to be considered for admission to the Spring 2021 Mammography Program. I realize that any
misleading information on this application may be cause for dismissal. I request the college forward to me at
the email address I have provided all correspondence, including personally identifiable information pertaining
to me from College records that is protected by FERPA.
Please check one:
r I agree to the above statement.
r I do not agree to the above statement.
By typing my name below and sending this form from my CT Community College
student email represent my agreement to the terms and conditions outlined above.
Your Full Name:
Date:
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Mammography Spring 2021 Program Application (Middlesex Community College)

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Completed 8 February 2021

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