STECH Surg Tech Program Application
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Do you have a High School Diploma or GED?
*
Yes
No
Do you have a current CPR certification?
*
Yes
No
Do you have any of the following certifications?
*
Certified Nursing Assistant (CNA)
Medical Assistant (MA)
Emergency Medical Technician (EMT)
Phlebotomist
None
Other
Upload a Copy of any Certifications (If applicable)
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Education
*
Include high school(s) and college/universities attended, dates attended and degrees received if applicable.
Healthcare Work or Volunteer Experience
Include the name of the agency, address, position and job description, and the start and end date that you worked there. List the most recent work experience first.
Essay: Why I Want to Be a Surg Tech
*
Browse Files
Drag and drop files here
Choose a file
Upload a Word doc or PDF of your essay entitled "Why I Want to Be a Surg Tech?" The essay must be typed and between 250-500 words.
Cancel
of
Acknowledgement & Signature: By signing below, I signify my understanding of the significant commitment of time, resources and work to complete a Surgical Technology Program. With that understanding, I choose to pursue the Southwest Tech Surg Tech Program with my best effort.
*
Submit
Should be Empty: