Temple College Radiologic Technology AAS Program Referral Form

Temple College Radiologic Technology Program Associate of Applied Science (AAS) — Program Referral Form

Instructions for the Applicant

Provide a blank Program Referral Form to the Referrer.
Provide the referrer with a postage-paid envelope addressed to:
Temple College
Radiologic Technology Program
2600 South 1st Street
Temple, Texas 76504

Do not return this form to the student.
Seal the completed form in an envelope.
Sign across the sealed envelope flap.
Mail directly to the address below:
Temple College
Radiologic Technology Program
2600 South 1st Street
Temple, Texas 76504

This student has applied to the Temple College Radiologic Technology program. This referral is in support of:

Applicant full name

Referrer full name:

Job title / position:

Organization / institution:

Email address:

Phone number:

Referrer affiliation to Temple College (check one)

Employer / Supervisor — Company name:

Faculty Member — Department name:

Affiliated Clinical Site Rep. — Facility name:

How long have you known the applicant?

In what capacity do you know the applicant?

Please rate the applicant on the following attributes by selecting the appropriate rating.
Attribute	Excellent	Above Average	Average	Below Average	N/A

Please provide a brief statement explaining why you recommend this applicant for the highly competitive Radiologic Technology Program.

I confirm that the information provided on this evaluation is accurate and reflects my honest assessment of the applicant.

Referrer signature

Sign by hand after printing

Date

Complete by hand after printing