Allied&Health&Application&
Important&Notes:&
• !"#$%&'&()%%()*#+,,+"-(.&/0+.&#&-',('"(!1)'')-""2)(3')'&($.+".('"($."2.)#(*&)*%+-&,4(
• !1&56($."2.)#()$$%+5)'+"-(51&56%+,'(7".(5"#$%&'&(*&')+%,("-()*#+,,+"-($."5&,,4(
• 87(9"0(:+,1('"()$$%9('"(#".&('1)-("-&($."2.)#;(9"0(#0,'(,0<#+'()(,&$).)'&()$$%+5)'+"-(7".(each%$."2.)#(:+'1(all%.&/0+.&*(
#)'&.+)%,4(=%%($."2.)#,(5)-(<&(7"0-*("-('1&(>?=@(:&<,+'&()'(:::451)'')-""2),')'&4&*0A-0.,+-2B)%%+&*B1&)%'1((
• C&-')%(@92+&-&(=$$%+5)-',D(87(9"0().&(5%)+#+-2(1+21(,51""%(51&#+,'.9(:+'1()(EFG(".(<&''&.;(,0<#+'()(5"$9("7(9"0.(1+21(,51""%(
'.)-,5.+$'(:+'1('1+,()$$%+5)'+"- 4 (
Check&one&program:(
( C&-')%(=,,+,'+-2(
HHHC&-')%(@92+&-&(==3(
HHHI#&.2&-59(J&*+5)%(K&51-+5+)-(((HH7)%%(((((,$.+-2
(
HHH@&)%'1(8-7".#)'+"-(J)-)2&#&-'(L."2.)#(==3
(
HHH>05%&).(J&*+5+-&(K&51-"%"29(==3(
HHHL1).#)59(K&51-+5+)-(
HHHL19,+5)%(K1&.)$+,'(=,,+,')-'(==3(
HHHM)*+"%"2+5(K&51-"%"29(==3(
HHHM&,$+.)'".9(!).&(==3((
HHHN&'&.+-).9(K&51-"%"29(==3
Advanced&Certificate&Programs:&
HHH>05%&).(J&*+5+-&(K&51-"%"29(O#0,'(1)P&(*&2.&&Q(
HHHM)*+)'+"-(K1&.)$9(K&51-"%"29(OJ0,'(<&(=MMK(!&.'+7+&*Q(
(
Emergency&Medical&Services&Programs:&
HHH=IJK(O)7'&.(IJKQ(HH7)%%(HH3$.+-2(
HHHL).)#&*+5(OJ0,'(<&(%+5&-,&*(=IJKQ(
(
Diagnostic&Medical&Sonography&Programs:&
HHHR&-&.)%(OSF;(=<*"#&-(T(&P&.9(&P&-(9&).Q(
HHH!).*+"P),50%).(OI51";(N),50%).B&P&.9("**(9&).Q(
(
1&Semester&Advanced&Certificates:&
HHH!"#$0'&*(K"#"2.)$19(O!KQ(
HHHJ)2-&'+5(M&,"-)-5&(8#)2+-2(OJM8Q(
HHHJ)##"2.)$19(
Info&Session:&
@)P&(9"0()''&-*&*()-(+-7".#)'+"-(,&,,+"-U(V&,(☐(>"((87(9&,;(☐(C)'&D(HHHHHHHHHHHHHHHHHHHHHHHHHHHHHHH(
(
Personal&Data:&
C)'&D(HHHHHHHHHHHHHHH(!1)'')-""2)(3')'&(8C(W(=(HHHHHHHHHHHHHHH((Required&before &tur n ing &in&program&application)(
>)#&(HHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHH(
(
(X),'( Y+.,'( J+**%&( J)+*&-(
3'.&&'(HHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHH
( (
!+'9(HHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHH( (3')'&(HHHHHHH( (Z+$(HHHHHHHHHHHHH( (
L1"-&(>0#<&.(O@"#&Q( ( O!&%%Q( ( H(
E-mail&Address&Othis%is%how%you%will%be%contactedQ(HHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHH((
(
Required&Demographic&Information:
&(Check&one&in&each&area)((
3&[D(J)%&(☐(Y&#)%&(☐(M)5&D(=,+)-AL)5+7+5(8,%)-*&.(☐\(=#&.+5)-(8-*+)-(☐\(=7.+5)-(=#&.+5)-(☐\(@+,$)-+5(☐\(!)05),+)-(☐\(F+B.)5+)%(☐(
C)'&("7(F+.'1D(J"-'1( C)9( (V&).( (In%compliance%with%Title%VI%Civil%Rights%Act%1964.(
&
Education:&
>)#&("7(@+21(351""%(HHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHH(V&).("7(R.)*0)'+"-(HHHHHHH(3'.&&'(=**.&,,( (
( H(!+'9( ( H(3')'&( Z+$HHHHHHHH( RIC( !"#$%&'&*( +-(
:1)'(9&).HHHHHHHH(
=.&(9"0(50..&-'%9(&-."%%&*()'()(5"%%&2&U( V&,☐(>"☐(+7(V&,;(:1&.&U(HHHHHHHHHHHHHHHHHHHHHHHHHH(
L.&P+"0,(!"%%&2&,(=''&-*&*D( =**.&,,(
C)'&,(=''&-*&*(
C&2.&&(I).-&*(
(
(
(
(
(
(
(
(
(
& &
Employment&Record:&(Start&with&most&recent)&
I#$%"9&.A=**.&,,(
C)'&,(]".6&*(
L",+'+"-(
M&),"-(7".(X&)P+-2(
(
(
(
(
(
(
(
(
&
Medical/Legal&Information:&
@)P&(9"0(&P&.(<&&-(5"-P+5'&*("7()(5.+#&("'1&.('1)-()(#+-".('.)77+5(P+"%)'+"-U(V&,☐(>"☐(
87(9&,;(*)'&U( H(C&,5.+<&(( H((
@)P&(9"0($.&P+"0,%9(<&&-( )55&$'&*(+-'"()-(>=@($."2.)#U(V&,☐(>"☐(
87(9&,;(:1&.&U( ]1&-U(HHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHH(
=.&(9"0(-":(".(1)P&(9"0.(&P&.(<&&-(%+5&-,&*A5.&*&-'+)%&*(+-()(1&)%'1(5).&(*+,5+$%+-&U(V&,☐(>"☐(
87(9&,;().&(9" 0(currently%%+5&-,&*A5.&*&-'+)%&*(+-()(1&)%'1(5).&(*+,5+$%+-&U(L%&),&(2+P&(%+5&-,&(-0#<&.;(,')'&;()-*(1&)%'1(5).&(*+,5+$%+-&((
@)P&(9"0(&P&.()$$%+&*(7".()(%+5&-,&A5.&*&-'+)%(+-()(1&)%'1(5).&(*+,5+$%+-&()-*(<&&-(*&-+&*U(V&,☐(>"☐(
87(9&,;($%&),&(&[$%)+-((HHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHH((
@),(9"0.(%+5&-,&A5.&*&-'+)%(&P&.(<&&-(,0,$&-*&*;(.&P"6&*;(".($0'("-($."<)'+"-U(V&,☐(>"☐(
87(9"0().&(-"'(50..&-'%9(%+5&-,&*(<0'(1)P&(previously%<&&-(%+5&-,&*A5.&*&-'+)%&*(+-()(1&)%'1(5).&(*+,5+$%+-&;(+-*+5)'&('1&(,')'0,("7(
%+5&-,0.&A5.&*&-'+)%D(( Please&attach&copies&of&all&valid&state/national&licenses/certificates.(
30,$&-,+"-H( L."<)'+"-( M&P"6&*( H(
For&Programs&that&Require&the&ATI&TEAS:&&
All&4&parts&of&ATI&Test&of&Essential&Academic&Skills&(TEAS)&+,('"(<&(')6&-("-(".(<&7".&('1&($."2.)#(*&)*%+-&(*)'&4(=(5"$9("7('1&(KI=3(
M&,0%',;(,1":+-2()%%(7"0.(+-*+P+*0)%(,5".&,(O8-*+P+*0)%(L&.7".#)-5&(L."7+%&Q;(is&required(:+'1('1&()$$%+5)'+"-4(87(9"0($%)-('"(.&')6&('1&(
=K8(KI=3()-*(:)-'('"(.&$%)5&('1&(.&,0%',;(2"('"($."2.)#(:&<,+'&()-*(P+&:(=K8(KI=3(7".(+#$".')-'(*&')+%,4(
(
Criminal&Background:&
Y"%%":+-2()55&$')-5&()-*($.+".('"(&-'&.+-2('1&(7+.,'(5).&& .(5"0.,&(+-(*&,+2-)'&*(1&)%'15).&($."2.)#,;(&)51(,'0*&-'(#0,'(0-*&.2"()(5.+#+-)%(
<)562."0-*(51&56(+-(".*&.('"(5"#$%9(:+'1($"%+5+&,("7()77+%+)'+-2(5%+-+5)%($.)5'+5&()2&-5+&,4(8'(,1)%%(<&('1&(,'0*&-'^,(.&,$"-,+<+%+'9('"(5"#$%9(:+'1(
+-,'.05'+"-,($."P+*&*(0$"-()55&$')-5&()-*($."P+*&('1&(.&,0%',(<9()(*&,+2-)'&*(*)'&4(K1&(51&56(:+%%(<&()'('1&(&[$&-,&("7('1&(,'0*&-'4(3'0*&-',(:1"(
*"(-"'(#&&'('1+,(.&/0+.&#&-'(+-()('+#&%9(#)--&.(".(:1",&(<)562."0-*(*"&,(-"'(#&&'()2&-59(,')-*).*,(:+%%(-"'(<&()<%&('"(,055&,,70%%9(5"#$%&'&
(((
'1&($."2.)#(".($).'+5+$)'&(+-(5%+-+5)%(."')'+"-,4(8%%+5+'(*.02(0,&;(5.+#+-)%(<)562."0-*(51&56(+,,0&,()-*(/0&,'+"-)<%&A$."<%&#)'+5(+##0-+_)'+"-(,')'0,(
#)9($.&P&-'(70'0.&(&#$%"9#&-'(".(5&.'+7+5)'+"-()-*(&['&.-,1+$(,+'&,;(&#$%"9&.,()-*(3')'&(".(L."7&,,+"-)%(F").*,(1)P&(.&20%)'+"-,()<"0'(*.02(0,&
(
)-*(5.+#+-)%(<)562."0-*,4(8-*+P+*0)%,(:+'1()(/0&,'+"-(5"-5&.-+-2('1+,(,1"0%*(,51&*0%&()-()$$"+-'#&-'(:+'1('1&(L."2.)#(C+.&5'".4(
Certificate&of&App lication&–&Please&read&carefully&and&sign:&
8()77+.#;()2.&&;()-*A".(0-*&.,')-*('1)'()%%(,')'&#&-',("-('1+,(7".#().&('.0&()-*()550.)'&\()-9(#+,.&$.&,&-')'+"-(".("# +,,+"-("7(#)'&.+)%(7)5',(#)9
(
.&,0%'(+-(#9(&[$0%,+"-(7."#()-9(=%%+&*(@&)%'1($."2.)#4(8(1&.&<9()0'1".+_&(!1)'')-""2)(3')'&(".("'1&.()$$."$.+)'&(3')'&(+-P&,'+2)'+P&()2&-5+&,('"(
#)6&()%%(-&5&,,).9(+-P&,'+2)'+"-,(5"-5&.-+-2(#&;(#9(:".6(1)<+',;(51).)5'&.;(".(#9()5'+"-(+-()-9('.)-,)5'+"-4(8(70.'1&.()0'1".+_&()-*(.&/0&,'(&)51(
7".#&.(&#$%"9&.;($&.,"-(2+P&-(),()(.&7&.&-5&;(&*05)'+"-)%(+-,'+'0'+"-;(".(".2)-+_)'+"-('"($."P+*&()%%(+-7".#)'+"-('1)'(#)9(<&(,"021'(+-(5"--&5'+"-(
:+'1('1+,()$$%+5)'+"-4(
K1+,()$$%+5)'+"-(+,(7".()-(=%%+&*(@&)%'1($."2.)#("-%94( F&7".&()-()$$%+5)-'(5)-(<&(5"-,+*&.&*(7".()55&$')-5&(+-()($."2.)#;(1&A,1&(#0,'(5"#$%&'&()%%(
)*#+,,+"-(.&/0+.&#&-',('"(!1)'')-""2)(3')'&(<9('1&($."2.)#(*&)*%+-&(*)'&4((
8()%,"(0-*&.,')-*(+'(+,(#9(.&,$"-,+<+%+'9('"(read%the%program%material%on%the%website%and%follow%the%program’s%application%checklist%in%order%to%
successfully%complete%the%program%admissions%process.% K1&()$$%+5)'+"-(51&56%+,'(:+%%(2+P&(9"0(.&/0+.&*(#)'&.+)%,('1)'(:+%%()55"#$)-9('1+,($."2.)#
(
)$$%+5)'+"-4(N+,+'('1&(>?=@(]&<,+'&()'(:::451)'')-""2),')'&4&*0A-0.,+-2B)%%+&*B1&)%'1(7".('1&($."2.)#(+-7".#)'+"-4(
=%%($."2.)#(#)'&.+)%,()-*A".(.&/0+.&*($."2.)#(,'&$,(#0,'(<&('0.-&*(+-()-*(5"#$%&'&*(on%or%before%the%program%deadline%date4( =**+'+"-)%%9;(+'(+,(
'1&()$$%+5)-'^,(.&,$"-,+<+%+'9('"(#)6&(,0.&('1&($."2.)#(7+%&(+,(5"#$%&'&()-*(.&#)+-,(0$B'"B*)'&4(
L.+-'(>)#&( (3+2-)'0.&( (C)'&HHHHHHHH(
Send&Program&Ap plication&and&required&materials&to:&
!1)'')-""2)(3')'&(!"##0-+'9(!"%%&2&(
>?=@(C+P+,+"-(B(*Attn:&Jennifer&Bryant&
`abc(=#-+5"%)(@+21:)9(
!1)'')-""2)(K>(de`bfBcbge( (
Y)[D(`hd4fge4hfhi(
I#)+%D(j&--+7&.4F.9 )-'k51)'')-""2),')' &4 &*0 (
(
(
(
(
Pub No 11-70-204101-3-7/17/HAL-100. Chattanooga State does not discriminate on the basis of race, color, national origin, sex, or disability. See our
full policy at https://www.chattanoogastate.edu/human-resources-employment-and-job-listings. (
