Date      _____________________

1.

Name

(last)

(first)

(middle)

(other last names that may appear on previous academic transcripts)

2.

Signature

Soc Sec #

3.

Permanent Address

(print)

(number and street)

(city)

(state)

(zip code)

4.

Mailing Address

(print)

(number and street)

(city)

(state)

(zip code)

5.

Home Phone

Work phone

(area code/number)

(area code/number)

6.

Give the name of a relative or friend living nearest to be notified in case of an emergency. (print)

(Name)

  (Relationship)

        (Phone)

Address: Number & St.

(city)

*(state)

(zip code)

7. High School Attended

School

City/State

Date of Entrance

Date of Leaving

Diploma Received

8. Give information below concerning Colleges or Universities attended:

Name of Institution

City/State

Date of Entrance

Date of Leaving

Diploma or Degree

9. If you have ever attended any School of Radiologic Technology, give the following information:

School

City/State

Date of Entrance

Date of Leaving

10. References: Each applicant is required to furnish three letters of recommendation. A teacher, counselor, employer, physician, or clergyman may submit these. List the persons whom you have selected to provide this information:

Name

Address

Position or Title

11. Attach or send Official high school and college transcripts (including MSSU transcript, if applicable).

12. Please complete and return before February 1^st to:

Missouri Southern State University

ATTN: Director, Radiologic Technology

3950 E. Newman Rd.

Joplin, MO 64801-1595

The above answers are true and complete, to the best of my knowledge.

To be considered for acceptance in the upcoming class, you must:

1.  Submit all requested application materials before February 1^st of the year you wish to enter the program. Click here to obtain Letters of Reference form.

2.  Send official (not copies) of high school and college transcripts (including MSSU transcript, if applicable) before February 1^st of the year you wish to enter the program.

3.  Submit proof of having job-shadowed in radiology prior to February 1^st of the year you wish to enter the program.

4.  Complete pre-requisite courses (see college catalog) prior to starting the program in the fall semester.

5.  Complete the Health Occupations Basic Entrance Test ( HOBET ) prior to February 1st of the year you wish to enter the program. You may call 417-625-9848 to schedule your HOBET test. A small fee will apply.

It is recommended that you call and confirm that all application materials have been received by the Director of the program prior to the February 1^st deadline (417-625-3118).

This publication will be made available in alternative formats upon request by contacting Alan D. Schiska 417.625.3118.