Checkth
e
Date
Name
MailingA
Residenc
e
EmailAd
d
Name,A
d

Techni
c
Previous
m
Haveyou
Dateyou
Doyouh
a
Technicia
Yes
Icertifyt
h

Signature
NOTE:Th
e
Informatio
n
Lamar Insti
faculty and
consistent
w
theRehabil
Resources.
e
programyo
u
ddress
e
Address
d
ress
d
dress,andT
e
c
alSchools
o
m
edicalexpe
everbeena
r
plantoente
r
a
veanymedi
n?
N
o
h
attheabov
e
e
Application fo
n
ProgrambyA
p
t
ute of Techno
staff member
s
w
iththeAssura
n
itationActof1
9
wanttoap
p
SocialSecu




e
lephoneof
p

o
rColleges
A
rience?
r
restedorco
n
r
theprogra
m
c
alproblems
o
e
information

r Admission an
d
ril15
th
.Applica
logy is an equ
a
s
are selected
w
n
ceofComplia
n
9
73.Inquiriesc
o
HealthIn
f
Ap
p
p
ly:
rityNo.
p
ersontobe
n
A
ttended
n
victedofan
y
m

limitingyou
istrueand
c
d
all other info
tionsreceiveda
a
l opportunity/
a
w
ithout regard
n
cewithTitleIX
o
ncerningappli
c
f
ormation
p
lication
f

HealthI
HealthI
n
City
City
n
otifiedinca
D
a
Explain
y
crimeothe
r
inperformin
g
orrect.

rmation reques
fterApril15
th
w
a
ffirmative acti
o
to their race,
ofthe Educati
o
c
ationofthese
r
Technolo
g
f
orAdmi
s
nformation
T
n
formatics(
C
T
D

S

CellPho
n
seofemerg
e
a
tesFrom/
T
r
thanamino
g
theduties
o
s
ted must be r
e
w
illnotbeconsi
d
o
n educational
color, creed, s
e
o
nAmendment
s
r
egulationsma
y
MailtheA
o
Lama
r
HealthInf
o
B
g
yProgra
m
s
sion
T
echnology(
A
C
ertificate)
T
elephone
D
ateofBirth
S
tate
State
n
e
e
ncy
T
o
Degr
e
rtrafficviola
t
o
faHealthIn
e
ceived by the
D
d
eredforadmis
s
institution and
e
x, age, handi
c
s
of1972,asa
m
y
bereferredto
t
pplicationfor
A
riginaltranscr
i
rInstituteof
T
o
rmationTech
P.O.Box10
0
B
eaumont,TX
7
m
A
AS)
ZIP
ZIP
ee/Certifi
c
Awarded
t
ion?
formation
D
irector of the
s
ion.
employer.St
u
c
ap or national
m
ended;Section
theDirectorof
H
A
dmissionsan
i
ptsto:
T
echnology
nologyProgra
0
61
7
7710
c
ate
Health
u
dents,
origin,
504of
Human
d
a
m
click to sign
signature
click to edit