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diagnostic medical sonography
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UCSD DIAGNOSTIC MEDICAL SONOGRAPHY PROGRAM APPLICATION
UCSD DIAGNOSTIC MEDICAL SONOGRAPHY PROGRAM APPLICATIONPROGRAM FOR YEAR __________
Last Name________________________________First Name______________________ Initial______
Street Address________________________________________________________________________
City____________________________________State____________________________ZIP_________
Home Telephone Number ( )______________________________________________________
Work Telephone Number ( )______________________________________________________
Birthdate _______________________ SS#_________________Email __________________________
Educational History High School__________________________________________________________________________
City___________________________________State_____________________________ZIP_________
Year Graduated_______________________________________________________________________
College______________________________________________________________________________
City__________________________________State______________________________ZIP_________
Year Graduated or Highest Year Attended________________________________________________
Major / Degree_______________________________________________________________________
College______________________________________________________________________________
City__________________________________State______________________________ZIP_________
Year Graduated or Highest Year Attended________________________________________________
Major / Degree________________________________________________________________________
Technical/Vocational Schools____________________________________________________________
City__________________________________State______________________________ZIP_________
Year Graduated or Highest Year Attended________________________________________________
Major_______________________________________________________________________________
Certificate/ Degree Obtained____________________________________________________________
Certifications/Licenses______________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Awards/Honors____________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Employment History (include last 10 years)
Employer____________________________________________________________________________
Address______________________________________________________________________________
City___________________________________State_______________________________ZIP_______
Telephone Number ( )_______________________________________________________________
Dates of Employment: Start Date___________________________End Date_____________________
Reason for Leaving____________________________________________________________________
Duties and Responsibilities______________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Employer____________________________________________________________________________
Address______________________________________________________________________________
City___________________________________State_______________________________ZIP_______
Telephone Number ( )_______________________________________________________________
Dates of Employment: Start Date___________________________End Date_____________________
Reason for Leaving____________________________________________________________________
Duties and Responsibilities______________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Employer____________________________________________________________________________
Address______________________________________________________________________________
City___________________________________State_______________________________ZIP_______
Telephone Number ( )_______________________________________________________________
Dates of Employment: Start Date___________________________End Date_____________________
Reason for Leaving____________________________________________________________________
Duties and Responsibilities______________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Employer____________________________________________________________________________
Address______________________________________________________________________________
City___________________________________State_______________________________ZIP_______
Telephone Number ( )_______________________________________________________________
Dates of Employment: Start Date___________________________End Date_____________________
Reason for Leaving____________________________________________________________________
Duties and Responsibilities______________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Reference____________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Reference____________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Reference____________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
I hereby certify that the above information is true and correct.
Signature____________________________________________DATE___________________________