Surgical Tech Application

Program Applicant Information

First Name

Middle Name

Last Name

Street Address

Address Line 2

City

State

Zip Code

Student ID#

Home Phone

Cell Phone

Alt Phone

San Juan College Student Email

Other Email

Prerequisites Completed

Freshman Composition:

Yes

No

What College:

Semester/ Year Taken:

Microbiology:

Yes

No

What College:

Semester/ Year Taken:

Human Anatomy & Physiology I:

Yes

No

What College:

Semester/ Year Taken:

Human Anatomy & Physiology II:

Yes

No

What College:

Semester/ Year Taken:

Medical Terminology:

Yes

No

What College:

Semester/ Year Taken:

Surgical Technology AAS Degree Courses Completed

Advanced Composition:

Yes

No

What College:

Semester/ Year Taken:

Public Speaking or Interpersonal Communication:

Yes

No

What College:

Semester/ Year Taken:

MATH 1155, MATH 1130, MATH 1220, or higher

Yes

No

What College:

Semester/ Year Taken:

Intro to Psychology or other:

Yes

No

What College:

Semester/ Year Taken:

Tell Us Why You Want to Get Into Our Program *

Have you attached your unofficial transcripts?

Yes

No

Do you have course work still to complete?

Yes

No

What courses are you taking or plan to take:

Are you classified as a New Mexico resident (In-State Tuition):

Yes

No

Transcript Result

I certify that my answers are true and complete to the best of my knowledge.
I understand that I am responsible to notify the program if any of the information contained here is changed or needs updating. I also understand that it is my responsibility to remain informed about the requirements for the program which included TEAS V Examination and the dates offered, Prerequisites, Residency Status, Admittance to San Juan College, Transfer Credit Requirements, San Juan College Student Policies and Procedures.

Signature

clear

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