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

Fillable Printable Sample Letter of Intent Form