VANDERBILT UNIVERSITY MEDICAL CENTER NEURODIAGNOSTIC TECHNOLOGY PROGRAM APPLICATION FOR ADMISSION Full Name:__________________________________________________________________________ Last First Middle Social Security Number:___________________________ E‐Mail address:________________________ Mailing Address:______________________________________________________________________ Street Apartment# ____________________________________________________________________________________ City State Zip Code Telephone Numbers: Home___________________________ Other___________________________ Educational Background: Please request that all colleges and professional schools attended send an official transcript of your grades. COLLEGE DATES ATTENDED DEGREE EARNED _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Professional Training Completed (include dates): _____________________________________________________________________________________ _____________________________________________________________________________________ Have you ever been convicted of a felony? Yes No Are you a U.S. Citizen? Academic Honors _ Yes No EMPLOYMENT EXPERIENCE: POSITION HELD EMPLOYER Comments (anything you would like us to know): References: ADDRESS DATES Each applicant must submit three (3) reference forms. Two (2) must be references from educational and/or work experiences. The third may be anyone, other than a family member, who has known the applicant for at least six (6) months. References may use the standard form provided with the application or send a personally written letter which covers the information on the form. Forms or letters should be mailed directly to the Program Director. Please list all individuals who will be used as references for your admission into the program. _______________________________________________________________________________________________________ Name Relationship to application Name Relationship to application Name Relationship to application NON‐DISCRIMINATRY POLICY STATEMENT Length of relationship Length of relationship Length of relationship In compliance with federal law, including the provision of Title IX of the Education Amendments of 1972, Sections 503 and 504 of the rehabilitation Act of 1973, and the Americans with Disabilities Act of 1990, Vanderbilt University does not discriminate on the basis of race, sex, religion, color, national or ethnic origin, age, disability, or military service in its administration of education policies, programs or activities; its administered programs; or employment. Inquires or complaints should be directed to the Opportunity Development Officer, Baker Building, Box 1809, Station B, Nashville, TN 37235. Telephone (615) 322‐4705 (V/TDD); fax (615) 421‐6871. Please have letters of reference and official transcripts sent directly to the program office at the address below. Riki Rager, R. EEG T, BS, FASET Neurodiagnostics Program Director Vanderbilt University Medical Center 1301 Medical Center Drive, B‐817 TVC Nashville, TN 37232‐5735 (615) 322‐6298 office (615) 936‐3522 fax riki.rager@Vanderbilt.Edu Please include $35.00 application fee (non‐refundable). Make checks out to Vanderbilt University Medical Center. I, __________________________, understand that the submission of this application form, the non‐refundable fee of $35 and the supporting documentation listed below is the first step in the application process. I understand that all documents will be retained permanently by the school regardless of my admission status. I understand that any falsified or inaccurate representation of my educational background will result in disqualification of my eligibility for admission. My application submission includes the following documentation: _______ Application form _______$35 non‐refundable fee (check made payable to VUMC) _______Transcripts for post‐secondary coursework My signature declares that I have read the Admission Policy and Student Health Policy. To the best of my knowledge, I will meet all minimum requirements for admission and student health standards prior to matriculation. If I am accepted as a student in the Vanderbilt University Medical Center, Neurodiagnostic Technology Program, I agree to abide by the program’s rules and regulations. _________________________________ ____________________________________ Signature Date