Hand-deliver, mail or email the completed application and documentation to:

Radiologic Technology Program
Temple College
2600 South 1st Street
Temple, Texas 76504

You can fill this application in on screen and then print it, or print it first and complete it by hand. Entries are not saved or submitted electronically, so print your completed application before closing this page.

Applicant information

Applicant contact details

First name

Middle name

Last name

Home Address

City

State

ZIP code

Personal e-mail

Temple College e-mail

Cell phone number

Emergency contact

Emergency contact name

Emergency contact phone number

Emergency contact relationship

Education

Schools attended

High school

Location

Diploma or GED

Date of graduation

College, university, or professional school (first)

College, university, or professional school

Degree, certificate, or hours

Dates of attendance

College, university, or professional school (second)

College, university, or professional school

Degree, certificate, or hours

Dates of attendance

Prerequisite courses

Have you completed the following prerequisite courses, and with what grade?

If you have not completed a course, and it will be completed prior to the first day of radiologic technology courses, enter “IP” for in progress.

Prerequisite courses and grades
Course	Grade
BIOL 2401 Human Anatomy and Physiology I	Grade for BIOL 2401 Human Anatomy and Physiology I
MATH 1314 College Algebra for Non-STEM Majors	Grade for MATH 1314 College Algebra for Non-STEM Majors
HPRS 2302 Medical Terminology for Allied Health	Grade for HPRS 2302 Medical Terminology for Allied Health

Have you submitted official transcripts for all prerequisite courses?

Yes

Official transcripts for completed courses must be on file by the application due date. Official transcripts for courses in progress at the time of application must be received before the class orientation date.

Other requirements

Answering “No” to any of the following, or failing to attach the required documentation, will disqualify your application.

Have you been accepted to Temple College?

Yes

You must be accepted to Temple College prior to applying to the Radiologic Technology program.

Have you completed the TSI Assessment?

Yes

Have you completed the ATI TEAS?

Yes

Your official ATI TEAS Individual Performance Profile must be attached and submitted with this application, or an official transcript can be sent to Temple College through ATI Testing.

Have you attended an AASRT information session within the last 12 months?

Yes

If yes, what date did you attend?

Information session attendance is mandatory for consideration of admission.

Referral Form

Have you submitted a referral? The referral form is included in this packet.

Yes

A referral is not required; however, you will be awarded ranking points if it is received by the application due date. Only one referral will be considered.

Certification and signature

I confirm that all information provided in this application and in the attached documentation is true and accurate. I understand that intentional falsification of application information or submission of fraudulent documentation may disqualify my application.

Applicant name (print)

Applicant signature

Sign here after printing this application.

Date of signature