DataARC  DATABASE SYSTEM

Health & Public Services Division

Respiratory Care Program

RRT Assessment Exam        400658-508100

Directions:

  1. Fill out this form (please print)
  2. Pay for RRT at the DACC Cashier’s Office Room 118.
  3. Cost: 1 payments of $65.00
  4. Have form stamped and signed by the Cashier.
  5. Return completed and signed form to Virginia Durant Room 191V.

Date:  _____________________________  Semester/Year: ______________________

Banner ID# or SSN:  ___________________________

_______________________________________________________________________

(Last Name)                                        (First Name)                                (M.I.)

Amount Paid:

                                                        

________________________________

Authorized Cashier Signature                           Cashier Stamp/Transaction No.