Echocardiography Certificate Application

Note: Space is limited in this program. In addition to applying to Clark State, students must also apply to this program. Please meet with your advisor to ensure all requirements are met.

Personal Information

First Name: *

Last Name: *

Student ID #: *

Phone Number: *

E-mail: *

Street Address: *

City: *

State: *

Zip: *

Academic Information

Do you have an associate's degree or higher in sonography? * This programs requires an associate's degree or higher in sonography.

Please name the institution where you earned your degree. *

What year did you graduate with your degree? *

Credential Information

What is your credential number? *

Are you registered with ARDMS or CCI? *

Employment Status

Are you currently employed as a sonographer? *

If yes, please indicate the modalities in which you are currently working.

Credential Verification

Please upload a copy of your registry ID card. *

Questions? Contact Us!

Megan Platfoot

Assistant Professor, DMS
937-328-7970
Email

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