ROWAN COLLEGE AT BURLINGTON COUNTY DIAGNOSTIC MEDICAL SONOGRAPHY PROGRAM APPLICATION
Please type or print clearly. Revised 11/2016
Name
Last First Middle
Address
Number & Street Town State Zip
Daytime Telephone Number __SSN:_______________DOB: / /
Other Name (s) used
High School Attended
Address
Date Entered Date Left Diploma Yes No If you did not graduate from High School, have you obtained a GED? Yes No College or other post-secondary schools attended. (List others on back if necessary.)
Name
Address
List two persons (other than relatives) for references. One must be of a professional or business association. Both reference letters must be enclosed in the same envelope with application and essay.
Professional Reference Personal Reference
Name Name
Address Address
City City
State & Zip State & Zip
Attach your 300- 500 word essay as to why you are interested in pursuing Diagnostic Medical Sonography as a career
I certify that the above information is correct.
(signature) (date)
Return this completed application and all required
documents to: Diagnostic Medical Sonography Program
Ms. Sepideh Abdollahzadeh MS, RDMS
DMS Program Director
Rowan College at Burlington County
601 Pemberton Browns Mills Road Pemberton, New Jersey 08068
Revision: DMS – 11-2016