GateWay Healthcare Information Form

Required fields are marked with an asterisk.

Program of Interest

Currently only the Clinical Research Coordinating program accepts information form submissions. More programs will be added here the future.

Field of study * Clinical Research Coordinating	Degree/Certificate * Associate of Applied Science Certificate of Completion (16 credit hours | 4 courses)
Describe why you are interested in this program * 200 character maximum length	Select your expected starting term * Spring 2010 Summer I 2010 Summer II 2010 Fall 2010

About You

Name (first, middle, last) *
first * middle last *

Former name(s) which may appear on transcripts

Home phone * Format as 602-123-4567	Mobile phone Format as 602-123-4567
Work phone Format as 602-123-4567	E-mail address *
Fill out the appropriate address fields below based on your country of residence. *
United States Address (Line 1) Street address, PO Box Address (Line 2) Apartment, suite, unit City State/Zip * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming	International Address (Line 1) Street address, PO Box Address (Line 2) Apartment, suite, unit City/Town State/Province/Region Postal Code Country

Field Experience

Have you had 2 or more years working in the healthcare system? * YesNo
Are you currently working in the field of clinical research? * YesNo If yes, where?
Site name and address

200 character maximum length

Describe any additional experience you have in clinical research

200 character maximum length

Which types of research are you involved in?

200 character maximum length

List certifications and degrees with the dates on which they were obtained

200 character maximum length

Previous Courses Taken

Check off all college level courses/equivalents below that you've taken: 4 credit Biology (BIO160)
3 credit Medical Terminology (HCC145)
3 credit Fundamental in Health Care Delivery
3 credit basic English
3 credit basic Math

Important Reminder

Please don't forget to submit your resume via e-mail to Cris Wells (wells@gatewaycc.edu)