Fillable SPC Radiologic Technology (South Plains College)

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SPC Radiologic Technology (South Plains College)

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1
SPC Radiologic Technology
2021-Program Application
Applicant Information
Please complete (type) all areas
Full Name:
Date:
Last
First
M.I.
Address:
Street Address
Apartment/Unit #
City
State
ZIP Code
Phone:
Email:
Student ID:
Have you ever been convicted of a felony?
YES
NO
If yes, explain:
Education
Please include all colleges, universities, vocational schools, allied health schools attended (including SPC)
Institution:
City & State:
Credits:
Did you graduate?
Degree Earned:
Institution:
City & State:
Credits:
Did you graduate?
Degree Earned:
Institution:
City & State:
Credits:
Did you graduate?
Degree Earned:
Disclaimer and Signature
Signature:
Date:
-Students in the Radiologic Technology Program with a criminal background, please be advised that the background may keep
you from obtaining credentials from the ARRT and/or a state radiation license. Students who have a question regarding their
background and credentials/license, please speak with the Program Coordinator or the Department Chair. The student may
request a criminal history evaluation from the applicable credentialing/licensing agency.
-I hereby certify that the information contained in this application is true and complete to the best of my knowledge. I have read
and understand the information and the technical requirements in the 2021-Application Information. 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 Radiologic
Technology Program.
-Please type the application information, then print the application. Sign, date, and bring the application to your appointment.
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SPC Radiologic Technology (South Plains College)

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Completed 4 February 2021

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