Name Email Address Street Address City State - Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code Country - Select -AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua & BarbudaArgentinaArmeniaArubaAscension IslandAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia & HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCanary IslandsCape VerdeCaribbean NetherlandsCayman IslandsCentral African RepublicCeuta & MelillaChadChileChinaChristmas IslandClipperton IslandCocos (Keeling) IslandsColombiaComorosCongo - BrazzavilleCongo - KinshasaCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d’IvoireDenmarkDiego GarciaDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard & McDonald IslandsHondurasHong Kong SAR ChinaHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao SAR ChinaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmar (Burma)NamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorth KoreaNorth MacedoniaNorwayOmanOutlying OceaniaPakistanPalauPalestinian TerritoriesPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSamoaSan MarinoSarkSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia & South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSt. BarthélemySt. HelenaSt. Kitts & NevisSt. LuciaSt. MartinSt. Pierre & MiquelonSt. Vincent & GrenadinesSudanSurinameSvalbard & Jan MayenSwedenSwitzerlandSyriaSão Tomé & PríncipeTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad & TobagoTristan da CunhaTunisiaTurkmenistanTurks & Caicos IslandsTuvaluTürkiyeU.S. Outlying IslandsU.S. Virgin IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWallis & FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Phone Number Last High School Attended Address of High School Date completed high school diploma or GED equivalency Date completed high school diploma or GED equivalency: Year Year196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023202420252026202720282029203020312032203320342035203620372038203920402041204220432044204520462047204820492050 Date completed high school diploma or GED equivalency: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Date completed high school diploma or GED equivalency: Day Day12345678910111213141516171819202122232425262728293031 Please request your official high school transcripts be mailed or electronically sent directly to the program from your high school. Transcripts must be received by Feb. 20th. Please email transcripts to Karen.Prouty@rwhs.org, or mail them to: Regional West Medical Center, School of Radiologic Technology, 4021 Avenue B, Scottsbluff, NE 69361 Most Recent College Attended Number of semesters attended at most recent college Years attended at most recent college Second College Attended (if applicable) Number of semesters attended at second college Years attended at second college Date of graduation from college Date of graduation from college: Year Year2014201520162017201820192020202120222023202420252026 Date of graduation from college: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Date of graduation from college: Day Day12345678910111213141516171819202122232425262728293031 ALL OFFICIAL COLLEGE TRANSCRIPTS MUST BE SENT DIRECTLY TO THE PROGRAM FROM THE ATTENDED COLLEGE. Please have them sent electronically to Karen.Prouty@rwhs.org. If mailing is the only option, please email the program and let them know they are coming by mail. ALL TRANSCRIPTS MUST BE RECEIVED BY FEBRUARY 20TH. Degree earned First Reference - Name The reference listed above will be emailed a link to a reference check survey. Please let them know this email is coming and ask them to respond promptly. First Reference - Email Address Second Reference - Name The reference listed above will be emailed a link to a reference check survey. Please let them know this email is coming and ask them to respond promptly. Second Reference - Email Address Third Reference - Name References listed above will be emailed a link to a reference check survey. Please let them know this email is coming and ask them to respond promptly. Third Reference - Email Address I hereby certify that the above information is true to the best of my knowledge Yes No I hereby certify that I have read the Technical Standards, found under the Policies tab to the left Yes No Do you feel you need accommodations for any of the information listed in the Technical Standards? Yes No Signature Date Date: Year Year20222023202420252026 Date: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Date: Day Day12345678910111213141516171819202122232425262728293031 Submit
English
Español
French
