Apply to a Certificate Program Continuing Studies Computed Tomography (CT) Certificate Magnetic Resonance Imaging (MRI) Certificate Apply to a Certificate Program Certificate Program Application MelroseWakefield Healthcare at Lawrence Memorial/Regis College "*" indicates required fields Choose which program you're applying for:* Computed Tomography (CT) Magnetic Resonance Imaging (MRI) Your Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Phone #*Primary Email* Enter Email Confirm Email Emergency Contact Name Emergency Contact Phone #Are you licensed through ARRT, NMTCB, or other nationally-recognized licensing body?* Yes No How did you hear about this program?* Co-worker Current program student or graduate www.lmregis.org website Other Consent* I agreeI attest that all information given on this application form is complete and accurate and understand that it will only be used to consider me for acceptance into the program. I also understand that, if accepted, my completing the program is not a guarantee of employment with MelroseWakefield Healthcare.Today's Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920CAPTCHA Δ
