Sample Letter of Intent Form

Letter of Intent Form
To be considered for admission into your program of choice, all sections of this form must be completed and
returned to the Program Manager on or before the deadline date designated by each program. Turn forms
in to room 3325 of the Health Science Center
PLEASE PRINT
A. Personal Data:
Name: _______________________________________ _____________________ ___________________
Last First Middle College ID #
Address: __________________________________________________________________ __________
Street City State Zip
Phone: (Home) ______________________ (Work) _____________________
B. Program of Intended Admission: (Circle One)
Degree: Dental Hygiene Diploma:
Nursing Dental Assisting
Surgical Technology Medical Assisting
Radiologic Technology Pharmacy Technology
Medical Office Management Practical Nursing
Diagnostic Medical Sonography
Pharmacy Technology
Respiratory Care Technology
C. Semester of Intended Admission: (Circle One)
Spring Summer Fall Year: _____________
D. COMPASS Scores:
Reading _____ Written _____ PreAlg _____ Alg _____
E. Courses Completed or Transferred Credit From Another College
________________________ ______________________
________________________ ______________________
________________________ ______________________
F. Current GPA at Columbus Technical College: _________________
I certify that the information given above is correct and I wish to be considered for admission.
_________________________________________ ____________________
Student Signature Date
Program Use Only
Total Program Score ____
Grades Verified _________
GPA Verified __________ ACCEPTED NOT ACCEPTED
SAT/ASSEST Verified ___________
Last updated on the web: August 17, 2011
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