Radiologic Technology MRI/CT Program Application

Which program are you applying for?

Name

First NameMiddle NameLast Name

NSHE ID (Student ID Number):

Email Address:

example@mail.tmcc.edu

Phone Number:

Please enter a valid phone number.Format: 000-000-0000.

Date of Birth:

Do you live in Nevada?

Do you intend to seek employment in Nevada upon completion of your program?

Education

Highest Degree Achieved:

1) School Name:

1) Degree Received at this School:

Transcripts must verify your degree.

1) Official Transcripts sent to TMCC?

2) School Name:

2) Degree Received at this School:

2) Official Transcripts sent to TMCC?

ARRT Credentials (check all that apply)

Other, please specify:

Clinical Education:

Clinical Education Site Information

Clinical Site:

Clinical Site Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Do You Currently Work at this Site?

I understand that I cannot represent myself as a TMCC student in this facility.

Have you confirmed that this Clinical Education Site is willing to enter into a partnership with TMCC, pending a signed affiliation agreement?

Minimum Exams Performed at this Site (check all that apply):

Other Exams Performed, If Any:

Number of Clinical Hours You Anticipate Per Week (for 16 Week Semester):

Clinical Education Site Contact Information

Clinical Site Dept. Manager's Name:

Clinical Site Dept. Manager's Phone Number:

Please enter a valid phone number.Format: 000-000-0000.

Clinical Site Dept. Manager's Email Address:

example@example.com

Student Supervisor's Name:

Technologist supervising the student and willing to work with TMCC for the student's clinical education component.

Student Supervisor's Contact Credentials:

Student Supervisor's Contact Phone Number:

Please enter a valid phone number.Format: 000-000-0000.

Student Supervisor's Contact Email Address:

example@example.com

MRI Safety

This information is essential for not only the student's own safety but that of the patient and other MRI personnel.

Indicate any conditions that apply to you personally:

Please Explain:

Describe any contraindications that would prevent you from performing routine tasks in the MRI Program as a student or future technologist?

File Uploads

Upload Unofficial Transcripts (other than TMCC) Verifying Your Degree:

Note that official transcripts must be submitted to TMCC's Admissions and Records Office. Please submit PDF or Word files only.

Upload Unofficial Transcripts (other than TMCC) Verifying Your Degree Status:

Upload Copy of ARRT Credentials:

Please submit PDF or Word files only.

Upload Copy of ARRT Credentials Status:

Comments (Optional):

Certification and Acknowledgment

By pressing submit, I certify that I have personally read and completed the information above, and that I understand the application criteria and procedures for the AMI Programs at TMCC.

I acknowledge that it is my responsibility to verify the receipt of transcripts with TMCC’s Admissions and Records Office. I accept full responsibility for requesting all required official documents.

Additionally, I understand that this degree/certificate leads to professional licensure in Nevada. Licensing requirements vary by state and territory, and relocating may impact my eligibility for licensure. If I do not reside in Nevada and/or do not plan to seek employment in Nevada, my application will be reviewed to determine eligibility for licensure in my state before acceptance into the program.

Please verify that you are human:

Sender Name: