Medical Radiography Program
Winchester Medical Center
220 Campus Boulevard, Suite 300
Winchester, Virginia 22601

 

CONTACT INFORMATION
First             Middle       Last
ALL other last names used   
 
Mailing Address     
 
City State Zip
 
Contact Information (Please check the location where you are most likely to be reached between the hours of 8am - 5pm)
Home  Business Cellular
Email Address  
Social Security Number
 
How did you become aware of this program? 
Have you ever applied for admission to one of Winchester Medical Center’s educational programs?
If yes, which one and when? 
 
In case of emergency, notify Relationship
Street Address     
 
City State Zip
 
Contact Information
Home  Business  Cellular 

 
 

EDUCATION
Are you a high school graduate?
GED? 
 
Name and address of high school attended
 
 College (select number of years completed)  
 
 Other schools attended (vocational, computer training, etc; select  number of years completed)   
 
Name and address of college, vocational school, etc.
 
Please specify any degrees or diplomas earned
 

EMPLOYMENT HISTORY
 
Begin with your current or most recent employment (include military service).
Please list ALL employment.

 

1. Place of employment Final salary
     Mailing Address     
    
     City State Zip
Employed from to
Your position
Reasons for leaving
Supervisor’s name Phone
 
2. Place of employment  Final salary
     Mailing Address     
     
     City State Zip
Employed from to
Your position
Reasons for leaving
Supervisor’s name  Phone
 
3. Place of employment Final salary
     Mailing Address     
     
     City State Zip
Employed from  to
Your position
Reasons for leaving
Supervisor’s name Phone
 
May we contact the employers listed above for references purposes? 
 
Please indicate by the appropriate number(s) any we should not contact and why  
Have you ever been discharged or asked to resign from a job?
If yes, please explain                 
Have you ever been convicted of a felony? 
If yes, please contact The American Registry of Radiologic Technologists at 651-687-0048 before submitting this application.          
 
Describe any course work, skills, or volunteer experience you have had that is relevant to this application.
Why do you want to enter this program?  What are your goals?

By my initials below, I certify that I have read this application.  I have not withheld any requested information and the responses on this application are true to the best of my knowledge.  I understand that any falsification or misrepresentation may be cause for rejection of this application. 
                             
 Initials of Applicant                                Date

The deadline for applications is December 1st of the current year.  Any applications which are received after the deadline will be considered for the following June.

NOTE:  ALL official High School and College transcripts must be delivered to the Medical Radiography Program, 220 Campus Boulevard, Suite 300, Winchester, Virginia 22601 from the institution(s) attended in an envelope sealed by the institution’s registrar.