Odessa College Radiologic Technology Program

Application for Admission

Completed application may be mailed to:

Odessa College

Radiologic Technology Program

201 W. University

Odessa TX 79764-7127

Program Application Deadline for Each Year is April 30!

Seeking admission: Month/Year Application Submitted: ______/______

Yeardesiring to start the program: ______

Applicant Information: PLEASE PRINT

Name: ______

Last First Middle

Social Security Number: ______OC ID# ______

Address: ______

Street, Apt #, etc.City State Zip

Mailing Address if different from above:______

E-Mail address:______

Other Name(s) on Transcript:______

Last First Middle

Phone Number with Area Code

Home: ______Work: ______Other: ______

Emergency Contact: ______

NameRelationship

Phone Number(s) with Area Code for Emergency Contact:______

Educational Background: High School/GED

______

Name of School Location Dates Attended Date Completed

College/University: List most recent first; list all attended

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Name of School Location Dates Attended Maj. Course of Study Degree Earned/Date

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Name of School Location Dates Attended Maj. Course of Study Degree Earned/Date

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Name of School Location Dates Attended Maj. Course of Study Degree Earned/Date

______

Name of School Location Dates Attended Maj. Course of Study Degree Earned/Date

List all work experience, beginning with the mostrecent.

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Facility NameLocation Dates Employed Duties: ______

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Facility NameLocation Dates Employed Duties: ______

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Facility NameLocation Dates Employed Duties: ______

Notice:

Successful Completion of the Radiologic Technology Program does not guarantee eligibility to take the ARRT licensing examination to become a radiologic technologist, ARRT(R).Eligibility is determined by the American Registry of Radiologic Technologists which requires all applicants to be of good moral character. Additionally, the State of Texas may restrict certification as a Medical Radiologic Technologist (MRT). Some events, such as having a felony ormisdemeanor conviction, including expunged offenses and deferred adjudication with or without prejudice of guilt,pleading no contest to any crime, having unresolved arrests, having pending criminal charges, having action taken againstyour health care provider license, having certain mental health disorders or a history of substance abuse MAY disqualify acandidate for ARRT and MRT certification.

The Radiologic Technology Program has selective admission criteria. Only one class is begun each year with 16- students in the class. Admission to the program is very competitive. Not all candidates who apply are accepted. See the Program Application Packet Information on the Program website at

Visit the program section of the school catalog and the rest of the Odessa College website at further information on admission criteria.

I certify that all of the information I have entered on this application is accurate and complete to the best of my knowledge. I understand that falsification of an application is cause for immediate program rejection or dismissal.

Date______Signature______

Odessa College does not discriminate in regard to sex, race, color, age, ethnic/national origin, religion/creed, marital status, veteran status, or disability.

Edited 10/4/2018