JEM COLLEGE
"
A Division of JEM Educational Services, LLC
"
271 Ott Street, Suite 23 Corona, CA 92882 (951) 549-0693 Fax (951) 738-9729
X-RAY TECHNICIAN STATE BOARD
EXAMINATION REVIEW
16.0 HOURS
*** Mail this Registration Form with payment to the address listed above ***
Confirmation of session will be phoned or emailed to you.
Make check/money order payable to: JEM Educational Services, LLC (Mail to above address)
Deadline for Registration closes 7 days prior to class start date
Name: _______________________________________________________________
Last First MI
Address: _____________________________________________________________
Street City State Zip
Contact phone: ( )___________________________________________________
E-mail address: ________________________________________________________
X-ray School attended: ___________________________ Date graduated: _________
List any x-ray permits that you currently hold and the permit number:
___________________________________________________ Permit #: _________
Please indicate one of the following:
a) I have not yet taken the exam b) I have taken the exam 1 time c) 2 times
d) I have received a letter from the state indicating that I need additional education
XT Exams:
Which categories did you NOT PASS? Please indicate most recent
non-passing scores.
IF YOU HAVE RECEIVED A STATE EXAM LETTER, PLEASE BRING IT TO
THE REVIEW SESSION (Day 1)
____ Core/Rad. Prot./score __________
____ Extremities/score __________
____ Chest/score __________
____ Torso-skeletal/score __________
____ $250.00 Cash, Check or Money Order (Enclosed)
____ $255.00 Credit Card ($5 convenience fee applies)
(Please call JEM COLLEGE to make credit card payment)
Please indicate payment:
Print Registration Form
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