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Cardiovascular Perfusion Program
Class of 2027 Application
Application Checklist
Application Deadline: July 15 of the application year
Additional Requirements: Acceptance is contingent upon successful completion of outstanding prerequisites (if any), immunization screening, immigration status clearance, Health Care Provider Basic Life Support/CPR certification, drug screening, clearance of and mandatory criminal background check.
Completed online application form.
Passport sized photo.
A $150.00 non-refundable application fee in the form of a money order or cashier's check (no personal checks) payable to UTHealth Cardiovascular Perfusion Training Program.
Official transcripts for any ongoing courses (Official transcripts must be sent from the educational institution directly to UTHealth Houston McGovern Medical School Cardiovascular Perfusion Training Program, 6410 Fannin St., Suite 703, Houston, TX 77030) No unofficial transcripts will be accepted. Applicants may submit official transcripts using the transcript service Parchment and find us by searching “UT Health Houston McGovern Medical School – Perfusion Program. Official transcripts can also be mailed using the address on our “Contact” page.
Proof of U.S. citizenship or permanent resident status.
Three letters of reference - uploaded by the applicant or directly from the author at https://med.uth.edu/perfusion/reference. Reference letter request form must accompany the submission. No personal emails will be accepted for professional references. Letters must come from their affiliated institution.
Documentation of any case observations and/or perfusionist interview using the associated form
Proof of completing a Baccalaureate degree or higher in the form of a final transcript and a copy of the diploma by October 1 of the application cycle.
Personal Information
Contact Information
First Name
Last Name
Preferred phone number
Email Address
Sex
Sex
Male
Female
Prefer not to answer
Headshot
Address
Street Address
Address Line 2
State
Zip/Postal Code
Country
Birth Date (mm/dd/year)
U.S. Citizen or Permanent Resident Status (Note: Currently, our program is unable to accept international students as the program is not accredited by the U.S. Department of Education.)
U.S. Citizen or Permanent Resident Status (Note: Currently, our program is unable to accept international students as the program is not accredited by the U.S. Department of Education.)
I am a U.S. Citizen
I have Lawful Permanent Resident (LPR) status
I am not a U.S. Citizen or Lawful Permanent Resident
Upload proof of citizenship (jpg or png):
Last 4 digits of your Social Security number:
Driver's license number and state of issuance:
Comments/Suggestions:
Emergency Contact Information
Contact Information
First Name
Last Name
Phone
Email Address
Street Address
Street Address Line 2
City
State
Zip/Postal Code
Country
Professional Experiences
Work experience #1
Employer Name
Location (City, State)
Dates (From-To)
Professional Title
Supervisor Name
Supervisor Title
Reason for Leaving
Work experience #2
Employer Name
Location (City, State)
Dates (From-To)
Professional Title
Supervisor Name
Supervisor Title
Reason for Leaving
Work experience #3
Employer Name
Location (City, State)
Dates (From-To)
Professional Title
Supervisor Name
Supervisor Title
Reason for Leaving
Work experience #4
Employer Name
Location (City, State)
Dates (From-To)
Professional Title
Supervisor Name
Supervisor Title
Reason for Leaving
Work experience #5
Employer Name
Location (City, State)
Dates (From-To)
Professional Title
Supervisor Name
Supervisor Title
Reason for Leaving
Work experience #6
Employer Name
Location (City, State)
Dates (From-To)
Professional Title
Supervisor Name
Supervisor Title
Reason for Leaving
Education
College/University
Name
City, State
Major/Course of Study
Did you graduate?
Dates (From-To)
College/University
Name
City, State
Major/Course of Study
Did you graduate?
Dates (From-To)
College/University
Name
City, State
Major/Course of Study
Did you graduate?
Dates (From-To)
Additional Information
Additional Education/Training and Certifications/Awards
Pre-Requisite Education Information
Note: Intro (or 101) classes are not currently accepted as one of our program prerequisite courses.
Biology Courses (12 Hours)
Note: Of the 12 total required hours, three hours must be in Cell Physiology or Cell Biology related courses.Please answer the following questions
Biology Course 1
College/University
Course Number
Credit Hours
Final Grade
Course Name
Biology Course 2
College/University
Course Number
Credit Hours
Final Grade
Course Name
Biology Course 3
College/University
Course Number
Credit Hours
Final Grade
Course Name
Biology Course 4
College/University
Course Number
Credit Hours
Final Grade
Course Name
Chemistry Courses (Eight Hours)
Chemistry Course 1
College/University
Course Number
Credit Hours
Final Grade
Course Name
Chemistry Course 2
College/University
Course Number
Credit Hours
Final Grade
Course Name
Chemistry Course 3
College/University
Course Number
Credit Hours
Final Grade
Course Name
Chemistry Course 4
College/University
Course Number
Credit Hours
Final Grade
Course Name
Human Anatomy & Physiology Courses (Six Hours)
Human Anatomy & Physiology Course 1
College/University
Course Number
Credit Hours
Final Grade
Course Name
Human Anatomy & Physiology Course 2
College/University
Course Number
Credit Hours
Final Grade
Course Name
Human Anatomy & Physiology Course 3
College/University
Course Number
Credit Hours
Final Grade
Course Name
Mathematics Courses (Six Hours)
Mathematics Course 1
College/Univerisity
Course Number
Credit Hours
Final Grade
Course Name
Mathematics Course 2
College/Univerisity
Course Number
Credit Hours
Final Grade
Course Name
Mathematics Course 3
College/Univerisity
Course Number
Credit Hours
Final Grade
Course Name
Physics Courses (Three Hours)
Physics Course 1
College/University
Course Number
Credit Hours
Final Grade
Course Name
Physics Course 2
College/University
Course Number
Credit Hours
Final Grade
Course Name
Educational References
Note: To complete the application process, please ensure you send the following link to your identified references listed below: https://med.uth.edu/perfusion/reference/
Reference 1
First Name
Last Name
Relationship
Reference 2
First Name
Last Name
Relationship
Reference 3
First Name
Last Name
Relationship
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