Eastern Campus Classroom: 1225 Ostrander Avenue, Riverhead, New York 11901 
Western Campus Classroom: 1979 Marcus Avenue, New Hyde Park, New York 11042 
Mailing Address: 1300 Roanoke Avenue, Riverhead, New York 11901 
(631) 548-6173 
E-mail: xrayschool@northwell.edu  
APPLICATION FOR ADMISSION Ð DUE MARCH 1, 2025!  (CLASS OF 2027) 
Part I: Information 
 
Name: ____________________________________________________________________________________ 
 
Street Address: _____________________________________________________________________________ 
 
Town: ________________________________________ State: _____________ Zip Code: _________________ 
 
Home Telephone #: ________________________________ Cell Phone #: ______________________________ 
 
Application Date: __________________________ 
*Please note that your SOCIAL SECURITY NUMBER WILL BE NEEDED IF YOU ARE ACCEPTED TO THE PROGRAM! 
 
Person To Be Contacted In Case of Emergency: ___________________________________________________ 
 
Telephone # of Emergency Contact: __________________________________ Relationship: _______________ 
 
Have You Ever Been Known By Another Name?    _________ YES __________ NO 
 
If Yes, What Was The Name? __________________________________________________________________ 
 
Are you legally eligible to attend school in the  
USA as per the Immigration Reform & Control Act?    ___________ YES ___________ NO 
 
Are you able to perform the duties of a student radiographer as stated in the Technical Standards on pages 8-12 of the Program Catalog? 
         ___________ YES _________ NO 
Are you a graduate with the minimum of an Associate Degree from an accredited college/university? 
If not, please state when your degree will be conferred by the college/university? 
         
_____________________ Date of Conferral   ___________ YES ___________ NO 
 
Have you ever had any previous training in Radiography?  ___________ YES ___________ NO 
Do you have any previous healthcare experience?   ___________ YES ___________ NO 
A ÒNoÓ response does not negate your admission to the school!  
 
What is your current email address? ___________________________________________________________ 
Please PRINT CLEARLY ANY CHARACTERS IN THE EMAIL ADDRESS!  
WE WILL CONTACT YOU USING YOUR EMAIL ADDRESS SUPPLIED UPON APPLICATION! 
 
PLEASE INDICATE YOUR PRFERENCE FOR YOUR CAMPUS CLASSROOM AS THERE ARE TWO CLASSROOMS TO SERVE THE MISSION OF THE PROGRAM: 
(Please indicate by 1st or 2nd choice!) 
 
Eastern Campus Classroom


  
 Western Campus Classroom


  
 


 
PLEASE READ!!!! 
The program cannot GUARANTEE PLACEMENT of your classroom preference.  Please understand that you also could be assigned to clinical sites throughout the entire Northwell system regardless of your campus classroom preference. Your Clinical Coordinator will assign your location once you are accepted to the program. 
*Reminder, your clinical site rotations are currently scheduled for every three months, but this could change to meet programmatic needs or clinical site needs. 
Example: Eastern Campus Classroom Student ÒAÓ could be assigned to North Shore University Hospital/Northwell, Manhasset. 
Example: Western Campus Classroom Student ÒBÓ could be assigned to Peconic Bay Medical Center/Northwell, Riverhead. 
 
 
 
 
 
 
 
 
 
 
 
 
 
Part II: Education Section 
College/University #1 (Most Recent Please!) 
 
Name of Institution: _________________________________________________________________________ 
 
Address of Institution: _______________________________________________________________________ 
 
Town, State and Zip of Institution: ______________________________________________________________  
 
Attended From: __________________________  Attended To: _____________________________________ 
 
Degree/Certificate Awarded: __________________________________________________________________ 
-------------------------------------------------------------------------------------------------------------------------------------------------- 
College/University #2 
Name of Institution: _________________________________________________________________________ 
 
Address of Institution: _______________________________________________________________________ 
 
Town, State and Zip of Institution: ______________________________________________________________  
 
Attended From: __________________________  Attended To: _____________________________________ 
 
Degree/Certificate Awarded: __________________________________________________________________ 
--------------------------------------------------------------------------------------------------------------------------------------------------  
High School/GED Certificate 
Name of Institution: _________________________________________________________________________ 
 
Address of Institution: _______________________________________________________________________ 
 
Town, State and Zip of Institution: ______________________________________________________________  
 
Attended From: __________________________  Attended To: _____________________________________ 
 
Did you graduate/complete the requirements for the diploma/certificate? _____________________________ 
 
 
 
***PLEASE CONTACT ALL EDUCATIONAL INSTITUTIONS TO HAVE YOUR OFFICIAL TRANSCRIPTS FORWARDED TO THE FOLLOWING ADDRESS: 
     Peconic Bay School of Radiologic Technology 
     1300 Roanoke Avenue (1 Heroes Way), Riverhead, New York 11901 
     Riverhead, New York 11901 
     Attention: Frank A. Zaleski, LMSW, MBA, BS RT ( R ), Program Director 
     Email: fzaleski@northwell.edu 
 
 
Part III: Employment Section 
Employer #1 (Most Recent) 
 
Name of Employer: __________________________________________________________________________ 
 
Address of Employer: ________________________________________________________________________ 
 
Town, State and Zip of Employer: ______________________________________________________________ 
 
Employed From: ____________________________  Employed To: ______________________________ 
 
What Is/Was Your Position? ___________________________________________________________________ 
 
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Employer #2 
Name of Employer: __________________________________________________________________________ 
 
Address of Employer: ________________________________________________________________________ 
 
Town, State and Zip of Employer: ______________________________________________________________ 
 
Employed From: ____________________________  Employed To: ______________________________ 
 
What Was Your Position? ___________________________________________________________________ 
 
-------------------------------------------------------------------------------------------------------------------------------------------------- 
 
 
 
 
Employer #3 
Name of Employer: __________________________________________________________________________ 
 
Address of Employer: ________________________________________________________________________ 
 
Town, State and Zip of Employer: ______________________________________________________________ 
 
Employed From: ____________________________  Employed To: ______________________________ 
 
What Is/Was Your Position? ___________________________________________________________________ 
-------------------------------------------------------------------------------------------------------------------------------------------------- 
Part IV: Professional/Academic References (Please-no relatives or friends!) 
1.
 Name: __________________________________ Relationship to Person: ______________________ 


 
Telephone #: _____________________________ Email Address: _____________________________ 
 
I have forwarded this person the Recommendation Letter Form. ________________________________ 
 
2.
 Name: __________________________________ Relationship to Person: ______________________ 


 
Telephone #: _____________________________ Email Address: _____________________________ 
I have forwarded this person the Recommendation Letter Form. ________________________________ 
 
3.
 Name: __________________________________ Relationship to Person: ______________________ 


 
Telephone #: _____________________________ Email Address: _____________________________ 
I have forwarded this person the Recommendation Letter Form. ________________________________ 
 
THESE INDIVIDUALS WILL BE THE SAME INDIVIDUALS WE WILL LOOK FOR LETTERS FROM IN YOUR APPLICATION PACKET. 
 
 
 
Part V: Requirements 
A)
 I have enclosed the application fee of $100.00 made payable to: ÒPeconic Bay Medical CenterÓ 


CERTIFIED BANK CHECK ____________    ___________ YES ___________ NO 
B)
 I have enclosed the Entrance Exam Form with the application Ð choosing the date(s) I will be taking the Entrance Exam.  I understand that there is a separate fee for the Entrance Exam of $75.00. I understand that the fee is FOR EACH EXAM as well as noting I may take the exam more than once, but no more than three times. PLEASE NOTE THAT YOU CANNOT SCHEDULE YOUR ENTRANCE EXAM OR TAKE YOUR ENTRANCE EXAM UNLESS WE HAVE RECEIVED THIS APPLICATION TO THE SCHOOL!  THERE ARE NO EXCEPTIONS! 


___________ YES ___________ NO 
C)
 I have enclosed the essay component of the application utilizing the ÒPERSONAL ESSAY FORM ATTACHMENTÓ or submitted the essay in the electronic application answering the question: ÒOur Program of Radiologic Technology is a two-year program dedicated to providing the healthcare environment with a well-rounded and competent professional Radiologic Technologist.  Please identify, in no more than 500 words, why you are choosing our school and your personal vision for your future in our profession.  You should also highlight any unique healthcare experiences with yourself or loved ones that are influencing your decision to become a Radiologic Technologist.Ó                       ___________ YES ___________ NO 


 
D)
 I have enclosed or will be contacting my educational institutions to obtain my most recent transcript(s) from my high school and colleges, including the proof of the completion of the course in Medical Terminology from an accredited college/university.   


*If you attended a different college/university for summer classes or winter classes besides your registered college/university that you have graduated/will graduate from, please contact those institutions as well. 
*Peconic Bay Program of Radiologic Technology is NOT responsible for any fees associated with any transcripts from any institution. 
*If I have not completed the course in Medical Terminology, please advise the program as to when it will be completed. 
Date of Completion of Medical Terminology course:  ___________ YES ___________ NO 
 
 _________________________________________ 
E)
 I have forwarded the three (3) Letters of Recommendation Forms to the individuals listed on the application packet.  I should remind these three people that it is their responsibility to return them either to myself or to the school ASAP! 


___________ YES ___________ NO 
 
F)
 I have included my most recent resumeÕ or CV for the admission committee to review. 


If not, when can the school expect the resumeÕ or CV from you? 
         ___________ YES ___________ NO 
 
G)
 I will complete an observation of the minimum of four (4) hours at any facility that will permit my attendance, complying with all regulations of privacy, by March 1, 2025. 


If I have scheduled it, but not completed it, please list the date of the observation on the form here. 
 
Date of Observation: ______________________  ___________ YES ___________ NO 
 
H)
 I will complete an observation in the radiology school classroom of two (2) Hours at either classroom that will permit my attendance, to have an opportunity to discuss my goals and see a classroom interaction.  I will use this time to discuss with the faculty any other concerns. 


 
         ___________ YES ___________ NO 
 
All of the answers given in this application are true and complete to the best of my knowledge.  If I am accepted into the Peconic Bay School of Radiologic Technology, I agree to abide by the rules, policies, and regulations set forth by the school and by Peconic Bay Medical Center/Northwell Health. 
 
Signature: ___________________________________________________ Date: ______________________ 
 
*A CERTIFIED BANK CHECK is a check that you receive from your bank.  A certified bank check is a personal check guaranteed by the check writerÕs bank. The bank verifies the account holderÕs signature and that he or she has enough money to pay, then sets aside the check amount for when itÕs cashed or deposited. *