Surgical Technology Program
Attention: Yolandra Beck
Phone: 662.243.2613
P.O. Box 100
Mayhew, MS 39753
SURGICAL TECHNOLOGY APPLICATION
PLEASE TYPE OR PRINT
Personal Information
Name:
Last First Middle Maiden
Social Security Number:
Address:
Street Apt.# P.O.Box City State Zip Code
Email address:
Telephone #s: Home
Cell
Name
EMERGENCY CONTACT INFORMATION
Relationship
Contact number
ASSOCIATE OF APPLIED SCIENCE (SUT)
Deadline for completed admission requirements (Application, ACT, and Transcripts):
July 1
st
Academic Information*
GED Test: Yes No
List all colleges attended (including EMCC):
to: Admissions
East Mississippi Community College
Admissions
Name and location of institution
Dates attended
Degree Awarded
Name of facility previously or currently
employed as a healthcare worker
Healthcare Position/Title
Credentials/Licensure
Have you ever been convicted of, pled no contest to, or are charges
pending against
you for a felony or misdemeanor or in any state/jurisdiction?
YES NO
I state that the fore going statements in this application are true and
accurate.
I am aware that omission of transcripts from other schools attended, or any
false,
misleading, or incomplete statements made on this application could be
grounds for
non-admission to, or later dismissal from, the Surgical
Technology Program.
Signed
Date
___________________
Non-Discrimination Policy
East Mississippi Community College is committed to assuring that the college
and its
programs are free from discrimination and harassment based upon race,
color, ethnicity,
sex, pregnancy, religion, national origin, disability, age, sexual
orientation, gender
identity, genetic information, status as a U.S. veteran, or any
other status protected by
state or federal law.
The following person has been designated to handle inquiries regarding the
non-discrimination policies:
Theresa Harpole
Director of Human Resources
P.O. Box 158 Scooba, MS 39358
Telephone: 662.476.5274
E-mail: tharpole@eastms.edu
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signature
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