SURGICAL TECHNOLOGY APPLICATION 2016

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1 SURGICAL TECHNOLOGY APPLICATION 2016

2 SURGICAL TECHNOLOGY APPLICATION FORM Arkansas State University-Newport COMPLETE ALL SECTIONS: TYPE OR PRINT Name: Last First Middle List other names on your educational records _ SS# / / Birth date: / / Sex: Male Female Address: Mailing Address Only City State Zip County How long at this residence? Phone Numbers: Home: Residence: Arkansas resident Non-resident of Arkansas Check one of the following: Asian or Pacific Islander Black/African American, non-hispanic Hispanic or Latino Other (specify) Cell/Other: Citizenship: United States Other (specify country) American Indian or Alaskan Native White, non-hispanic Non-resident alien Did you: Graduate High School? Yes No Year Graduated High School attended: City/State of High School Earned GED? Yes No Year earned State earned_ Will this be your first time at ASU-Newport? Yes NO

3 Is this an application for readmission? Yes No Readmission candidates are required to take the TEAS V Exam for placement. Readmission is based on seat availability, previous academic performance, performance on the TEAS V examination and all other applicable information. Application Deadline: June 1 st, See special notice below for the alternate list for late applicants. ADMISSION TEST TEAS V Students must score above (52 %) on the TEAS V test for the Adjusted Individual Total Score to be eligible for admission. Students will be ranked according to their highest score on the TEAS V. The test may only be taken twice per admission cycle. In addition, students must meet all admission requirements of the college to be eligible for admission to the program. SPECIAL NOTICE: Students that do not meet the application deadline may submit an application after the deadline if they will have met all requirements by the end of the second summer term Late applicants meeting all application requirements at the end of the second summer term will be placed on an alternate list below all other applicants that met the June 1 st, 2016 d e a d l i n e for possible consideration for any available seats that may be vacant in 2016 fall semester. Colleges Attended List all colleges attended including classes attended/completed for CNA, EMT, Paramedic or Mental Health Tech. TERMS: NAME OF INSTITUTE: CITY/STATE: HOURS/CREDITS EARNED:

4 Have you ever been subject to academic discipline or probation: Yes If yes, please complete this section: Name of Institution: Location (City, State): Dates of Attendance: Reason for Leaving: No Have you ever attended another ST program? Yes No If yes, you must submit a Letter of Good Standing from the Dean/Director of the previous surgical technology program(s) where you attended. This/These letter(s) must be sent directly from the Dean(s)/Director(s) to the Director of Surgical Technology. List all surgical technology programs you have previously attended & locations: 1. Have you ever been convicted of a misdemeanor or felony? Yes No 2. Do you currently engage in drug-related behavior, including the use of mood-altering drugs/substances and/or alcohol that would affect your functional abilities to perform while working as a surgical technologist? Yes No If you answered Yes to any of the above statements, please circle the appropriate number(s) and explain: Circle: 1 2 Explanation: Many healthcare facilities will not allow those with criminal convictions or evidence of drug related behavior the opportunity to attend the clinic component of the training. Those with a history of a criminal record or drug related behavior may not be able to complete the program requirements to earn the certificate. The Surgical Technology program at Arkansas State University-Newport (Marked Tree) provides the skills necessary to work in the state of Arkansas in the Surgical Technology field. This program is not nationally accredited and the State of Arkansas does not have a state board/exam for this field. Therefore, graduates of this program are not eligible to for a certification exam which is required in some states.

5 ADDITIONAL INFORMATION New applicants and readmissions must submit a new application and required documents each year to be considered for admission or readmission to the Surgical Technology program. All applicants must fulfill all college admission requirements. In addition to regular procedures, international students must meet all conditions that apply to the admission and enrollment of international students. All courses will be taught in the English language. Disclaimer: The Surgical Technology Program at ASU-Newport reserves the right to make changes at any time in the application process, individual courses, and the curriculum leading to a degree or certificate, as well as policies published in the Arkansas State University-Newport Catalog, student handbooks and web. Return completed applications to: ASU-Newport (Chris Madden) 7648 Victory Blvd. Newport, AR Or ASUN Marked Tree (Jeremy Wortham) US 63 E Marked Tree, AR I affirm that all information supplied is complete and accurate and that I have not been dropped for disciplinary reasons from the last institution attended. I understand that any misrepresentation of facts on this application could be cause for refusal of admission, cancellation of admission, or suspension from the university. I also understand that upon acceptance into this Surgical Technology program, I will be subject to Criminal Background checks and Drug testing by ASU-Newport, it agents and affiliated clinical sites. Applicant s Signature Date of Application

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