Cardiovascular Perfusion Program

Application Checklist

Application Deadline: August 1 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.

Proof of U.S. citizenship or permanent resident status

Three letters of reference - mailed or emailed directly from the author. 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

Your Name(Required)

First Last

Your Email Address(Required)

Preferred Phone Number(Required)

Sex(Required)

Female

Male

Other

Prefer not to answer

Headshot(Required)

Max. file size: 200 KB.

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Birth Date(Required)

U.S. Citizen or Permanent Resident Status(Required)

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

Emergency Contact Information

Name

First Last

Relationship to Applicant

Phone

Email

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Professional Experience

Please list your professional background in chronological order beginning with your most recent experience.

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

Please list your educational background in chronological order beginning with your most recent experience.

College/University

Location (City, State)

Dates (From - To)

Major/Course of Study

Did you graduate?

Yes

No

In Progress

College/University

Location (City, State)

Dates (From - To)

Major/Course of Study

Did you graduate?

Yes

No

In Progress

College/University

Location (City, State)

Dates (From - To)

Major/Course of Study

Did you graduate?

Yes

No

In Progress

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 (Nine Hours)

Note: Of the nine required hours, three hours must include Cell Physiology or Cell Biology related courses.

College/University

Course Number

Course Name

Credit Hours

Final Grade

Biology Courses (Nine Hours)

College/University

Course Number

Course Name

Credit Hours

Final Grade

Biology Courses (Nine Hours)

College/University

Course Number

Course Name

Credit Hours

Final Grade

Biology Courses (Nine Hours)

College/University

Course Number

Course Name

Credit Hours

Final Grade

Chemistry Courses (Eight Hours)

College/University

Course Number

Course Name

Credit Hours

Final Grade

Chemistry Courses (Eight Hours)

College/University

Course Number

Course Name

Credit Hours

Final Grade

Chemistry Courses (Eight Hours)

College/University

Course Number

Course Name

Credit Hours

Final Grade

Chemistry Courses (Eight Hours)

College/University

Course Number

Course Name

Credit Hours

Final Grade

Human Anatomy & Physiology Courses (Six Hours)

College/University

Course Number

Course Name

Credit Hours

Final Grade

Human Anatomy & Physiology (Six Hours)

College/University

Course Number

Course Name

Credit Hours

Final Grade

Human Anatomy & Physiology (Six Hours)

College/University

Course Number

Course Name

Credit Hours

Final Grade

Mathematics Courses (Six Hours)

College/University

Course Number

Course Name

Credit Hours

Final Grade

Mathematics Courses (Six Hours)

College/University

Course Number

Course Name

Credit Hours

Final Grade

Mathematics Courses (Six Hours)

College/University

Course Number

Course Name

Credit Hours

Final Grade

Physics Courses (Three Hours)

College/University

Course Number

Course Name

Credit Hours

Final Grade

Physics (Three Hours)

College/University

Course Number

Course Name

Credit Hours

Final Grade

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

Case Observation/Perfusionist Interview Form

The Program is aware of difficulties in observing cases at many institutions due to HIPAA regulations. We offer an opportunity for observation through our program (fees apply). It is in the best interest of the applicant to observe to get a better understanding of the profession. If the applicant is unable to observe, we highly recommend interviewing with some perfusionists regarding the profession.

Date

Procedure

Institution

Trainee Comments

Date

Procedure

Institution

Trainee Comments

Date

Procedure

Institution

Trainee Comments

Perfusionist Interview Information

Date

Perfusionist Name

City, State

Perfusionist Contact Info

Date

Perfusionist Name

City, State

Perfusionist Contact Info

Date

Perfusionist Name

City, State

Perfusionist Contact Info

Date

Perfusionist Name

City, State

Perfusionist Contact Info

Trainee Statement

Please write a brief essay describing your background, interests, hobbies, as well as your reason(s) for applying to the UTHealth Houston - Cardiovascular Perfusion Training Program. In addition, please describe why you think you would be an ideal candidate for this program.

Trainee Statement

How did you hear about our program?

2025 Application

Application Checklist

Personal Information

Emergency Contact Information

Professional Experience

Education

Additional Information

Pre-Requisite Education Information

Educational References

Case Observation/Perfusionist Interview Form

Perfusionist Interview Information

Trainee Statement