What program/course are you applying for?
If yes, list organizations.
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APPLICATION FOR ADMISSION TO THE
RADIOLOGIC TECHNOLOGY PROGRAM
School of Health Sciences

ALL areas within a red border are required fields.
First Name
Last Name
Middle Name
Student Information
ARRT Number (if applicable):
Start Date of Program Applying To
Registry, Certification or License No.
Student G-Number
Zip Code
Mobile Phone #
Zip Code
Email Address
Home Phone
State
State
City
City
Permanent Address
Present Address
Please note that you must be an ARRT registered/registry eligible technologist to apply for any advanced modality course in radiologic technology.
Other name(s), if any, you have used for work or educational records
Are you registered, certified or licensed by any state and/or national organization, *other than the ARRT*?
Are you a US Citizen?
If additional space is needed, attach a file using the Attach Button on the last page.
Employment History
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If you are not a US Citizen, attach all US immigration status documents to this application.
LIST MOST RECENT POSITION FIRST. If presently employed, may we contact?
Year
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