INSTRUCTIONS: Return this application, three reference forms, and official transcripts of all high school, college, and te...
Page 2
WORK EXPERIENCE
Employer and Location (street, city, state, zip) Position
Hours
Per Week
Dates
From To
REFERENCES
N...
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EDUCATION/TRAINING

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EDUCATION/TRAINING

  1. 1. INSTRUCTIONS: Return this application, three reference forms, and official transcripts of all high school, college, and technical training to: Nuclear Medicine Technology Program, Department of Radiology, The University of Iowa Hospitals & Clinics, Iowa City, IA 52242. THE DEADLINE FOR ALL APPLICATION MATERIALS IS FEBRUARY 1. Please print legibly. NAME - - Last Name First Middle/Maiden Social Security Number MAILING ADDRESS Street City State Zip Code ( )Phone number where you can be contacted concerning this application Area Code Number Email address where you can be contacted concerning this application (if available) Are you seeking admission to the program as a candidate for a bachelor’s degree? [ ] Yes [ ] No EDUCATION/TRAINING School Name and Location (city, state) Attended From To Degree or Certification Date Received High School College Other CURRENT AND PROJECTED COURSE SCHEDULES Please indicate below all college course work that you are currently taking and any other that you expect to complete before entering the program. Current Registration Projected Registration College: College: Session (Sem. or Qtr.): 20 Session (Sem. or Qtr.): 20 Course Number Course Title Credits (s.h./q.h.) Course Number Course Title Credits (s.h./q.h.) The University of Iowa requests this information for the purpose of making an admission decision about you. No persons outside the University are provided this information, except for items of directory information such as name and local address. If you fail to provide the required information, the University may not consider your application.
  2. 2. Page 2 WORK EXPERIENCE Employer and Location (street, city, state, zip) Position Hours Per Week Dates From To REFERENCES Name of Reference Title/Occupation Daytime Phone # Employer and Location (street, city, state, zip) STATEMENT OF PURPOSE In the space below state your reasons for selecting Nuclear Medicine Technology as your field of study and include your professional interests, goals, and plans after certification. Please feel free to attach any additional pages to this form. Please sign and date your application below. Applicant’s Signature Date Signed

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