Application form. Academic year applying for. Please circle modality. CT MRI Both. Social Security Number. Address. Phone (work) (home) address

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1 1 Application form Bon Secours St. Mary s Hospital s School of Medical Imaging Continuing Education Important Note Bon Secours School of Medical Imaging makes selection of applicants without regard to race, religion, color, national origin, sex, disability or age. Please Type or Print in Ink Academic year applying for Please circle modality. CT MRI Both Name Last First Middle Maiden Social Security Number Address Phone (work) (home) (cell) address State of Legal Residence US Citizen Yes No If no, give a status and attach a copy of your card. Country Visa Type Visa Number Date Issued / /

2 2 *Minimum GPA of 2.5 required to apply to all programs. Contact school if under 2.5 GPA Criminal Background If you have ever been convicted or are currently under indictment for of a misdemeanor or felony you must notify the Program Director of the school before proceeding with this application. Candidates who have been convicted of any type of offense other than speeding violations must seek pre-approval through the American Registry of Radiologic Technologists. The ARRT can refuse approval, which would bar the candidate from seeking work in Radiography. A criminal background check is part of our enrollment process. Please refer to the Background Check policy for further information. A conviction will not necessarily preclude you from consideration for admission, but Failure to notify the Program Director could be grounds for dismissal from the program. Yes No If yes, attach a letter of explanation. Licensure and Education List any current licenses, registrations or certifications that you hold: Type License Number State Expiration List names of all schools that you have attended, begin with current or most recent. Start Date Completion Date School Name Address Course Degree/ Grade completed

3 3 Employment History List all current and former employers. Attach additional pages as needed. Each applicant must Submit 2 letters of Reference from a person other than family. References should be from someone who knows you professionally or academically. Have you ever been terminated from employment Yes No If yes, attach a letter explaining. Have you ever been employed by a facility that is now in the Bon Secours Health System Yes No If yes, Date and Location May we contact your previous employers? Yes No If no, please attach letter explaining.

4 4 Application Packet Checklist: Completed Application Application & Fee ($50.00) Official/ Sealed copies of All College Transcripts 2 Letters of Reference in sealed envelopes Sign & date application on page 5. When applying for MRI, Magnetic Resonance Imaging please check one of the following supporting disciplines and provide a copy of registration. ARRT(R) Radiography ARRT (RT) Radiation Therapy ARRT (N) Nuclear Medicine Technology or NMTCB ARRT(S) Sonography or ARDMS Current enrollment in a an accredited program in Radiography, Radiation Therapy, Nuclear Medicine or Sonography program. When applying for CT, Computed Tomography please check one of the following supporting disciplines and provide a copy of registration. ARRT(R) Radiography ARRT (RT) Radiation Therapy ARRT (N) Nuclear Medicine Technology or NMTCB Current enrollment in a an accredited program in Radiography, Radiation Therapy or Nuclear Medicine. Please submit completed application packet as listed above. ATTN: Stacy Whittington School of Medical Imaging 8550 Magellan Parkway Suite 1100 Richmond, VA Continued on next page

5 5 Read Carefully Before Signing: It is my understanding that I shall not be considered for admission to the Bon Secours School of Medical Imaging until I have submitted all materials as specified by the school. I further agree to inform the school of any changes of my 1) plans to attend the School of Medical Imaging 2) address 3) legal name. I understand that withholding information requested in the application or giving false information on any documentation may make me ineligible for admission to/or continuation in the Bon Secours School of Medical Imaging. I further understand that an applicant who meets all requirements is not guaranteed admission into the program. I hereby certify that facts set forth in this application are true to the best of my knowledge. Date of Application Signature Rev