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Computerized Tomography Program Application

Allied Health Certificate Program

Galveston College Computerized Tomography Program has a selective admissions process. This process is non-discriminatory on the basis of race, color, national origin, gender, age, qualified disability, marital status, veteran’s status, or sexual orientation in admissions to the program.

Note: It is the student’s responsibility to provide the program director written notification of any changes in contact information.

Please complete the form below for application to the Computerized Tomography Program. Answers to all items are required. If a question does not pertain to you, simply put NA for the response.

 

CT-Online with ClinicCT-Online without Clinic


Application date:

Semester applying for:

Year:

Student ID Number:

Last 4 digits of SS#:

Date of Birth (may require documentation)

Current place of employment and position:

(If you want to complete the clinical at your place of employment please complete Preferred Clinical location below.)

Graduating from school/program:

GPA:

Last Name

First Name

Middle/Other Name

Mailing Address

City

State

Zip Code

Phone Number

Email


Do you need a clinical location arranged for you?
YesNo

Preferred clinical location:

Hospital/clinical name:

Contact name:

Title:

Contact phone number:

Contact email:


I also understand that if I choose to participate in the Clinical portion that the Background Check and Drug Screen are my responsibility to complete prior to the start of the program at my own expense.

Contact

Mary Koebele
CT Program Director

Phone

409-944-1270

Fax

409-944-1511