Fillable Rad Tech Application (Clovis Community College)

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Rad Tech Application (Clovis Community College)

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1
Radiologic Technology
Program Application
Applicant
Information
For important application and transcript deadline information, please
refer to page one of the Radiology Technology Program application
process.
Please print legibly, fill out completely. List additional information on separate sheet if
necessary.
Name Social Security Number
Address
City State Zip
_______________________________________________________________________________________________
Phone: Home/Cell Email
Note: If you change your address or telephone number after turning in your
application, you must notify the Allied Health Division in addition to the
Admissions and Records Department.
Is this your first application to the program? Yes
No
If no, list the year of previous application.
Have you attended another college since you last attended CCC? Yes
No
If yes, where did you attend?
Signature
Applicant's Signature Date
C
2
Provisional Agreement
I understand that my application to the Radiologic Technology Program at Clovis Community College is on a
PROVISIONAL BASIS pending receipt of transcripts from the following school(s)/college(s)
1.
2.
3.
4.
I agree to complete my Radiologic Technology Program application file no later than the published deadline. I understand that if my
file is not complete by the published deadline it will not be forwarded to the Radiologic Technology Program Director.
Applicant’s Signature: ______________________________________ Date: ______________________________
Clovis Community College Radiologic
Technology Program Acknowledgement Form
1. Please enter your full name.
2. Do you have all your prerequisite courses complete?
Yes
No
If no, what classes will you be completing this summer?
3. Are you aware that you are required to travel in this program?
Yes
4. Are you aware that you are required to provide your own transportation to the clinical
sites?
Yes
5. Do you understand that the clinical sites are located in Eastern New Mexico and West
Texas and the farthest site is located 120 miles from Clovis?
Yes
6. Do you understand that admission to program is based upon GPA?
Yes
7. Do you understand that as a student in the Radiology Program it is your responsibility to
have all immunizations current?
Yes
8. Are you aware that you will be required to complete and pass multiple background
checks as required by clinical sites or be dismissed from the program?
Yes
Please print the completed program acknowledgement form and turn in with your
completed application to admissions.
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Rad Tech Application (Clovis Community College)

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Completed 25 July 2020

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