School of Nuclear Medicine Technology Application Application Deadline is January 30, 2010

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1 School of Nuclear Medicine Technology Application Application Deadline is January 30, 2010 PERSONAL INFORMATION (Please print clearly) Today s Date Name (in full) City, State and Zip Code Phone Number Social Security Number Residency Status Citizen Other Permanent Resident ; Alien No Licensure / Registration Type: Number: State: Date Issued: Have you ever been convicted of, or pled guilty to a crime? YES or NO If YES, Please give exact details of convictions, offense, where committed, sentencing court, date of sentence, and nature of sentence on separate sheet. Convictions/guilty pleas are not an automatic bar to acceptance. EMPLOYMENT EXPERIENCE (Radiology Students must supply a reference from Clinical Coordinator) Employer (most recent) Phone Number with Area Code Dates of Employment Nature/Position of Employment Reason for Leaving Employer (other) Phone Number with Area Code Dates of Employment (to/from) Nature/Position of Employment Reason for Leaving

2 EDUCATION Radiology School City and State Dates of Attendance Degree Awarded (if any) Date of Graduation College (most recent) City and State Dates of Attendance Degree Awarded (if any) Date of Graduation Post-Secondary School City and State Dates of Attendance Degree Awarded (if any) Date of Graduation

3 REFERENCES - Please include references and list sources Name Phone Number with Area Code Occupation Relation to Applicant Name Phone Number with Area Code Occupation Relation to Applicant HOW DID YOU BECOME AWARE OF THE SCHOOL OF NUCLEAR MEDICINE TECHNOLOGY OF ABINGTON MEMORIAL HOSPITAL? (Check ALL that apply) Abington Memorial Hospital School of Radiologic Technology Abington Memorial Hospital School of Radiologic / Nuclear Medicine Technology Open House Abington Memorial Hospital Web Site Abington Memorial Hospital Employee High School Counselor / College Fair Friend/Family Member Other I HEREBY APPLY FOR ADMISSION TO ABINGTON MEMORIAL HOSPITAL SCHOOL OF NUCLEAR TECHNOLOGY. I CERTIFY THAT THE INFORMATION INCLUDED IN THIS APPLICATION IS TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE. I FULLY REALIZE THAT OMISSION OR FALSIFICATION OF APPLICATION INFORMATION WILL BE CONSIDERED SUFFICIENT REASON FOR REJECTION OF THIS APPLICATION OR DISMISSAL FROM THE PROGRAM. IF ADMITTED, I AGREE TO ABIDE BY ALL SCHOOL POLICIES. Signature of Applicant Date

4 PLEASE READ CAREFULLY Sign and Return this form with your Application & References PHYSICAL EXAMINATION WITH DRUG and/or ALCOHOL TEST & CRIMINAL BACKGROUND CHECK I understand that for the protection of the hospital s patients, any offer of acceptance I may receive will be conditioned upon my taking and passing a pre-entrance health physical examination. This examination, which will include a drug test, will be given by a physician, registered nurse, or nurse practitioner in the Employee/Student Health Department of Abington Memorial Hospital. I also agree to take a physical examination and or drug/alcohol test, at such other times as required by the hospital (to the extent permitted by law) during the period of my enrollment in the program. I agree to abide by all Abington Memorial Hospital procedures and policies. I understand the application submitted by me will go under an investigation process, I therefore authorize previous employers/education institutions, to furnish the following the Nuclear Medicine Technology Program; transcripts, letters of reference, and any/all information pertinent to admission to the program. I understand that this application will be considered on the basis of the information I have furnished. Acceptance is also contingent upon a successful criminal background check. I understand these tests are only required if I am accepted into the program. Any false, misleading, or incomplete statements made by me, or any omission of materials that shall prevent this application from being totally processed, shall be cause for termination of the application process. Any false or misleading information discovered after admission will be cause for immediate dismissal from the Program. Signature of the Applicant Date: Rev

5 School of Nuclear Medicine Technology INSTRUCTION TO THE APPLICANT: Please complete the following before distributing this form. Applicant Name (in full) Applicant Signature & Date INSTRUCTION TO THE RECOMMENDER: The person named above is applying for admission into the School of Nuclear Medicine Technology at Abington Memorial Hospital. He/she has requested your recommendation. We would be grateful for your honest evaluation of the applicant by responding to the questions below. The School of Nuclear Medicine Technology at Abington Memorial Hospital strives to educate qualified applicants in the field of Nuclear Medicine Technology. Each applicant is evaluated from several perspectives before final admission is granted. Among the areas that are evaluated are personal character, previous record, academic potential and work ethic. Please mail this completed form with your signature to AMH School of Nuclear Medicine Technology, 2500 Maryland Road, Suite 212, Willow Grove, PA Please check which of the following descriptions apply to the candidate: Inadequate Adequate Strong Outstanding Unknown Academic Potential Problem Solving / Thinking Skills Motivation / Initiative Maturity / Judgment Communication Skills Creativity Reliability Punctuality / Absenteeism Emotional Stability Support System Cooperation / Team Work Skills Personal Responsibility Cultural Awareness Honesty / Integrity

6 Please answer the questions below to the best of your ability. We would be grateful for your honesty. How long have you known this applicant? In what capacity do you know the applicant? What do you considered to be this applicant s major strength? What do you considered to be this applicant s major weakness? Is this person sensitive to others from different backgrounds, different personalities. Give examples if necessary. If you were an employer, would you hire this person to work for you? Please comment on why you believe this applicant would be suitable for the School of Nuclear Medicine Technology. I recommend this applicant I recommend this applicant with enthusiasm I recommend this applicant with reservation I do not recommend this applicant Recommender Name (in full) Recommender Signature & Date

7 School of Nuclear Medicine Technology INSTRUCTION TO THE APPLICANT: Please complete the following before distributing this form. Applicant Name (in full) Applicant Signature & Date INSTRUCTION TO THE RECOMMENDER: The person named above is applying for admission into the School of Nuclear Medicine Technology at Abington Memorial Hospital. He/she has requested your recommendation. We would be grateful for your honest evaluation of the applicant by responding to the questions below. The School of Nuclear Medicine Technology at Abington Memorial Hospital strives to educate qualified applicants in the field of Nuclear Medicine Technology. Each applicant is evaluated from several perspectives before final admission is granted. Among the areas that are evaluated are personal character, previous record, academic potential and work ethic. Please mail this completed form with your signature to AMH School of Nuclear Medicine Technology, 2500 Maryland Road, Suite 212, Willow Grove, PA Please check which of the following descriptions apply to the candidate: Inadequate Adequate Strong Outstanding Unknown Academic Potential Problem Solving / Thinking Skills Motivation / Initiative Maturity / Judgment Communication Skills Creativity Reliability Punctuality / Absenteeism Emotional Stability Support System Cooperation / Team Work Skills Personal Responsibility Cultural Awareness Honesty / Integrity

8 Please answer the questions below to the best of your ability. We would be grateful for your honesty. How long have you known this applicant? In what capacity do you know the applicant? What do you considered to be this applicant s major strength? What do you considered to be this applicant s major weakness? Is this person sensitive to others from different backgrounds, different personalities. Give examples if necessary. If you were an employer, would you hire this person to work for you? Please comment on why you believe this applicant would be suitable for the School of Nuclear Medicine Technology. I recommend this applicant I recommend this applicant with enthusiasm I recommend this applicant with reservation I do not recommend this applicant Recommender Name (in full) Recommender Signature & Date

Social Work Department

Social Work Department BACHELOR OF SOCIAL WORK DEGREE PROGRAM Application For Admission Application Date Application for (Semester) (Year) Personal Information: Name Home Address City State ZIP Home Phone