Mammography Program Application - Fayetteville Technical Community College

Name(Required)

First Last

Phone(Required)

Student ID #(Required)

Email(Required)

ARRT ID #

Clinic Option(Required)

Traditional

Non-traditional

(Note: If the non-traditional clinic option is chosen, it is the student's responsibility to provide the contact information for the site representative that approved the use of the facility. Also, the site must sign an affiliation agreement with the college.)

Please list in order of preference, your top five preferred clinical facilities:

Clinical facilities often have issues regarding their acceptance of students and may not be available during your rotation. Additionally, available facilities are offered to mammography students on a first-come, first-served basis.

Semester for which you are applying(Required)

Education
Transcripts MUST be sent to FTCC Admissions Department

College(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

From(Required)

To(Required)

Diploma?/Degree?/Certificate?(Required)

Major(Required)

Radiography Work Experience

Employer

Address

Street Address Address Line 2 City State ZIP Code

From

Department

Job Title

Students must have radiology licensure in the clinical education site's state, where applicable. Admission into the program is contingent upon the authorization of the state in which the student resides.

Signature of the Applicant:(Required)

Date(Required)

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