Surgical Technology: voice: 956.364.4805 voice: 800.852.8784
Department Chair: Robert Sanchez voice: 956.364.4805 voice: 800.852.8784 Email: Surgical Technology
Mailing Address: Surgical Technology TSTC Harlingen 1902 North Loop 499 Harlingen, TX 78550
Location: Located in the Sen. Eddie Lucio Health Science Technology Building
Office Hours: M - F: 8:00 AM - 5:00 PM Sat., Sun.: Closed
| Print Application
Date______________________
Interviewed: ___________
Accepted Date: ____________
Semester:_________________ |
APPLICATION FOR ADMISSION
Must be submitted in person
| Application Date:____________________Social
Security:____________________
Last Name:______________First Name:_____________Middle
Name:_________
Street Address:__________________P.O. Box:__________Phone:_____________
City:__________________County:__________State:_________Zip
Code:_______
Have you been accepted for admission to Texas State Technical
College?
[ ] Yes
[ ] No
EDUCATIONAL BACKGROUND:
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DEGREE/
CERTIFICATE |
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EMPLOYMENT HISTORY:
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POSITION HELD |
CITY/STATE |
DATES |
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PHYSICAL RECORD: List any physical or medical conditions
that may need proper observation
to prevent accidents or injuries to you.
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Do
you hereby authorize your Doctor(s) to release record to this
school and clinical site?
[
]Yes
[ ]No
Are you planning to
apply for Financial Aid? [
] Yes
[ ] No
If yes, have you contacted and applied with Financial
Aid Office located at the Student Services Building? [
] Yes [ ]No
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I understand that the Admissions
Committee will not regard this application as complete until all supporting documentation has
been received; therefore, it is to my interest to see that these
are submitted as promptly as possible.
It is also my understanding that official transcripts sent
directly from each school I have attended must be received by the
Admissions Office as soon as possible at the end of each successive
semester or semester for as long as my application is being considered.
I
also understand that as a Surgical Technology student, I will be
exposed to blood and body fluids.
Texas State Technical College will not be held responsible
for injury sustained during clinical experiences.
As a student, I am required to carry my own medical and accident
insurance. Proof of
insurance, immunizations, and physical exam must be kept on file
in the Surgical Technology Department and forwarded to the hospitals
upon request. In addition,
I also understand that as a Surgical Technology student, I will
be required to obtain the Hepatitis B vaccinations.
The
hospitals (clinical sites) have the right to approve or disapprove
my application for clinical experience and
may conduct a background check.
Hospitals reserve the right to refuse clinical privileges
to any student.
I further
understand that the information submitted herein will be relied
upon by officials of Texas State Technical College to determine
my status for admission. I
certify that the information in this application is complete and
understand that the submission of false information is grounds for
rejection of my application, withdrawal of any offer of acceptance,
cancellation of enrollment, or appropriate disciplinary action.
Applicants Signature:_______________________________________________________
Date:_____________________
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This completed application form must be submitted to:
Texas State Technical College
Surgical Technology Program
C/O Eddie Lucio Health Science Technology Building
1902 North Loop 499
Harlingen TX 78550-3697
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