Program Application

Application for Admission to the Clinical Research Coordinating Program

You must also submit your resume via email to Cris Wells

Which CRC program are you applying for?	16 credit hour, 4 course CRC Certificate of Completion Associate of Applied Science in Clinical Research Coordinating
I plan to begin the program with a class starting in:	Spring 2008 Summer 2008 Fall 2008
First Name:
Middle Initial:
Last Name:
Address:
City:
State:
Zip:
Former Name(s): (which may appear on transcript)
Home Phone:
Cell Phone:
Work Phone:
Email:
Are you currently working in the field of clinical research?	Yes    No
If yes, where?
Site Name & Address:
Which types of research are you involved in?	(Maximum characters: 200) You have characters left.
If not currently in the field, do you have any experience in clinical research?	Yes    No
Why are you interested in this program?	(Maximum characters: 200) You have characters left.
List Certifications and/or Degrees and date(s) obtained:	(Maximum characters: 200) You have characters left.
Have you had 2 or more years working in the healthcare system?	Yes    No

Have you previously taken college level courses or their equivalent for:

Please check all that apply
4 credit Biology (BIO160)
3 credit Medical Terminology (HCC145)
3 credit Fundamental in Health Care Delivery
3 credit basic English
3 credit basic Math

Please don't forget to submit your resume via email to Cris Wells