Critical Care Transport

Critical Care Transport Account Creation Form

Applicant Information

First Name

Middle Name

Last Name

Other Names Used

Gender

Date of Birth

Email

Citizenship Status

U.S. Citizen

Permanent Resident (Green Card holder)

Other

Other Please Explain

State Issued ID Upload

Permanent Resident Card Upload

Other Ethnicity

* Explanation of Ethnicity Request
This information is requested to issue a student ID number. The information is collected for institutional, state, and federal reports, it is optional, and will be used in non-discriminatory manner, consistent with applicable civil rights laws.

U.S. Address

Country

Street

City

Region

Postal Code

Domestic Phone Number

International Students Only Foreign Address

Country

Street

City

Region

Postal Code

International Phone Number

Passport Upload

Experience Information

Resume/CV Upload

Are you applying as a Nurse or Paramedic?

Nurse

Paramedic

Nursing License Number

and

Paramedic License Number

Education Information

Your highest level of education?

High School

Undergraduate

Graduate/Master

Other

Other please explain

Certifications

I hereby certify that the information on this form is complete and correct to the best of my knowledge. I agree to abide by the policies, rules, and regulations at The University of Texas at Tyler. I authorize the university to verify the information I have provided. I further understand that this information will be relied upon by the officials of the University in determining my admission to the program and that the submission of false information is grounds for rejection of my application, withdrawal of an offer of acceptance, cancellation of enrollment, and/or disciplinary action.

I understand that admission to Critical Care Transport is not a guarantee of admission to any other program at The University of Texas at Tyler.

I understand that I also understand that this application is only valid for 1 (one) year from the date recorded below. Any delay in arrival or starting of coursework beyond one year requires resubmission of application and all other documents, including the application fee.

I understand that I must make my own arrangements for housing and transportation.

Applicant's Signature (type full legal name)

Current Date

Student Type

Start Term