Application For Admission
Personal Information
Name
Address City State Zip
Phone number Email address
Have you ever been convicted of a felony?
Education
School name Location Years attended Degree received Major
Date:
Social Security:
Student ID
If yes, please explain.
Have you previously applied to, or been enrolled in a healthcare program?
If yes, when and where?
Did you finish the program?
If not, please explain:
*If you did not complete the program, a letter from the program in which you did not complete, stating that you are in good standing with the program, must be submitted with your application*
Signature Disclaimer
- ALL items (1-5) must be completed before the Surgical Technology Application can be submitted. Applicants
needing to take additional TSI remedial courses in Summer I can apply the Second week of June with
verification of course enrollment.t
- Students in the Surgical Technology Program who may have a criminal background, please be advised that
the background may keep you entering the program due to clinical site policies. Students who have a question
regarding their background, please speak with the Program Coordinator or the Department Chair.
- I hereby certify that the information contained in this application is true and complete to the best of my
knowledge. I understand that any misrepresentation or falsification of information is caused for denial of
admission or expulsion from the college. I understand that the information contained in this application will be
read by the faculty and staff of the South Plains College Surgical Technology Program.
Signature:
Date:
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signature
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