Middle Tennessee Cardiovascular Institute is Authorized and Regulated by the Tennessee Higher Education Commission.

APPLICATION FOR ADMISSION Middle Tennessee Cardiovascular Institute 397 Wallace Road Building C Suite 214 Nashville, TN 37211 Email: admin@mtcvi.com Fax: (615) 499-4102 Middle Tennessee Cardiovascular Institute is Authorized and Regulated by the Tennessee Higher Education Commission. Instructions: Please print or type. Be sure to answer each question. All documents submitted to the college become part of the official files and cannot be returned. I acknowledge that academic or disciplinary concerns may be discussed by the appropriate official and my parents or legal guardian. The $50 Application fee is required for this application to be accepted for admission. This fee is non-refundable PART A: STUDENT BACKGROUND ID # - For Office Use Only Social Security/Admission Number - - Name (Last, First, Middle) Maiden Name Date of Birth Gender Male Female Local Address City State Zip code Permanent Address City State Zip code Telephone Number Cell Phone Number Work Phone Number Email Ethnic Data- select all that apply These are items used to satisfy State/Federal requirements and in no way affects the admission decision Asian Latin/Hispanic American Indian/Alaskan Native Hawaiian/Pacific Islander Black/African American White International/Non-Resident Marital Status Single Widowed Married Divorced SUPPLEMENTAL INFORMATION 1. If either parent has attended college, what is their highest level of education? 1 Year 2 Years 3 Years Completed Bachelor s or Above Degree 2. Are you a single parent with legal custody of minor children? Yes No 3. Are you a person who has been responsible for home and family without pay and are returning to school to get marketable skills? Yes No 4. Have you been employed in the past 5 years, part-time and/or full-time? Yes No 5. Have you ever been convicted of a misdemeanor or felony? Yes No Page 1 of 10

EDUCATION INFORMATION List ALL previously attended colleges or universities below in chronological order. Do not abbreviate. (Please attach a separate sheet if necessary.) Applicants are also required to turn in all official transcripts with their completed Application Packet. Failure to disclose this information may result in non-admission or dismissal if enrolled. NOTE: An official transcript that includes grades from the last semester in attendance is required from ALL institutions previously attended. Institution Type Name & Address City/State Dates of Attendance High School/ GED College/University Did you graduate? Type of Certificate/ Degree Earned Vocational School MILITARY STATUS Are you a veteran or a dependent (including spouse) of a veteran? Yes If yes, check one: Veteran Dependent If you are active duty military, where are you stationed? CITIZENSHIP STATUS (Please check one option) U.S. Citizen (US) Permanent Resident (RA) (The applicant must present the Permanent Resident Card to the Administrative Director at Middle Tennessee Cardiovascular Institute for verification prior to college acceptance.) A copy of the Card will be made and included with this admissions application. In the absence of documentation, a student is charged out-of-state tuition and fees. Non-U.S. Citizen (NA) (If you checked Non-U.S. Citizen, you must state your country of citizenship here: ) Are you here on a VISA? Yes No If yes, state type of VISA: VISA #: To all VISA Holders: You must submit your original documentation to the Administrative Director for verification prior to Program acceptance at MTCVI. Country of Citizenship: EMERGENCY CONTACTS Last Name: First Name: Middle Initial: Relationship to you: Parent/Guardian Spouse Other Phone Number: - - Last Name: First Name: Middle Initial: Relationship to you: Parent/Guardian Spouse Other Phone Number: - - Page 2 of 10

PART B: SHORT ANSWER 1. Please share your motivation for beginning a career as a Registered Diagnostic Cardiac Sonographer. 2. The lessons we take from past challenges often prepare us for future successes. Recount a time when you faced a challenge, setback, or failure. How did it affect you, and what did you learn from the experience? 3. Why did you choose Middle Tennessee Cardiovascular Institute to continue your education? 4. What motivates you as a student? 5. Please take the next page to write anything we should know about you and why you should be admitted for enrollment to Middle Tennessee Cardiovascular Institute. Page 3 of 10

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APPLICANT S AGREEMENT (Please read carefully and sign) In making this application, I accept and agree to abide by the policies and regulations of Middle Tennessee Cardiovascular Institute. I certify that the information on this application is complete and accurate. Failure to provide accurate information may be just cause for dismissal from the Program. I understand that it is my responsibility to notify the Administrative Director any change in the information contained in this application. Applicant Full Name (Please Print): Applicant Signature: Date: Please submit the following documents along with this application to apply to the Program. Without all necessary documents for submission, an application will be considered incomplete and may be deferred or rejected. Please refer to the MTCVI 2017-2018 Catalog for more information. Application (along with the $50 Application fee. This fee is non-refundable.) Official Transcripts from ALL Colleges/Universities attended Reference Letters (2) Copy of Applicant s Resume Immunization Records Measles Mumps Rubella (MMR) Varicella (Chicken Pox) TB Test (To be done the week before class starts) Tdap (Tetanus, Diphtheria, Pertussis) Background Check (Background checks must be current for the full year of attendance. This Background check must be completed within thirty (30) days of completing the application. Background checks exceeding thirty (30) days will disqualify application.) Drug Test (Drug test can be taken at any verified facility that uses urine drug screen, 10-panel drug screen, AND uses "zero tolerance" drug screening. Students will usually receive results in 3-10 days. Drug screenings must be done within two (2) weeks of application.) Screening interview (Screening interviews will be scheduled following the submission and receival of a student s finalized application. Interviews will be scheduled by the Administrative Director by phone or email. Students should expect for interviews to be scheduled within two (2) weeks of application. FOR OFFICIAL USE ONLY Date application entered: New Application Updated Application If updated, last semester attended: Processed by: Initial: Official Process Date: Page 5 of 10

RECOMMEDNATION FORM Middle Tennessee Cardiovascular Institute 397 Wallace Road Building C Suite 214 Nashville, TN 37211 Email: admin@mtcvi.com Fax: (615) 499-4102 Middle Tennessee Cardiovascular Institute is Authorized and Regulated by the Tennessee Higher Education Commission. ID # - For Office Use Only Recommender must complete this section Thank you for taking the time to complete this form. Your comments are valuable to us. Please complete this form with the knowledge that it is retained in the student s file should he/she attend Middle Tennessee Cardiovascular Institute. In accordance with the Family Educational Rights and Privacy Acts of 1974, matriculating students have access to their permanent files, which may include forms such as this. Colleges do not make admission records accessible to applicants, students who are not admitted or students who decline admission offers. Spelman College is committed to administering all educational policies and activities without discrimination on the basis of race, color, religion, national or ethnic origin, age, or disability. The admission process at private institutions like Spelman College is exempt from the federal regulations implementing Title IX of the Education Amendment of 1972. Thank you for your cooperation. Recommender s name: Please check one: High School Counselor High School Teacher College Professor College Advisor Employer Other (please specify) How long have you known the applicant? In what context? What are the first words that come to mind to describe the applicant? Complete this section where applicable. School College Board/ACT Code Current mailing address number and street city/town county state country zip How would you compare the applicant to his/her peers? One of the top few I have encountered in my career Outstanding (top 5%) Excellent (next 10%) Above Average Average Below Average No basis for judgment Do you believe the applicant will be academically successful at Middle Tennessee Cardiovascular Institute? Yes Probably so Doubtful No Do you recommend that this applicant be admitted to Middle Tennessee Cardiovascular Institute? Yes Yes, but with reservations No How familiar are you with Middle Tennessee Cardiovascular Institute? I know Middle Tennessee Cardiovascular Institute very well. I know something about Middle Tennessee Cardiovascular Institute. I know very little about Middle Tennessee Cardiovascular Institute. Page 6 of 10

Please tell us about the applicant s most important characteristics, personally and academically. What do you feel sets this applicant apart from other students? Why do you feel this student is well suited for Middle Tennessee Cardiovascular Institute? We would appreciate information that would help us learn more about the applicant, such as the applicant s scholastic promise and achievement, personality, special accomplishments or talents and level of motivation. If you would like to speak with an admissions counselor about this student, please call our office at (615) 447-8284. Printed Name of Recommender _ Signature of Recommender Date / / Position Telephone Number ( ) # of 2 Required- For Office Use Only of 2 Page 7 of 10