Dorothy "Mimi" Roush RPT Exam Fee Endowed Scholarship

APPLICATION
PERSONAL DATA
Full Name*

First NameLast Name
Mailing Address*

Street Address

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CityState / Province

Postal / Zip CodeCountry
Primary Phone Number*
E-mail*
Have you paid for your certification test with AMT?*
Unfortunately, you do not qualify for the RPT exam fee scholarship. If you have any questions, please contact AMT at AMTlearning@americanmedtech.org.

EDUCATION AND SCHOOL ACTIVITIES
High School where you graduated or now attend (or G.E.D.)*

School Name

Street Address

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Enrollment Dates*
Graduation or G.E.D. Date of Certificate*

MonthDayYear
Date
Are you currently enrolled in an educational program?*
Please select your field of study*
Unfortunately, you do not qualify for the complimentary RPT exam fee. If you have any questions, please contact AMT at AMTlearning@americanmedtech.org.
Name of Institution*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

CAREER GOALS
Describe in 500 words or less why you have chosen your career*

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Head-shot (Optional)

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I grant to American Medical Technologists (AMT), its representatives and employees the right to publish photographs of me and my property in connection with the above-identified subject. I authorize AMT to copyright, use, and publish the same in print and/or electronically. I agree that AMT may use such photographs of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and web content.
I have read and understand the above.
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APPLICATION