Online Application

Name

FIRST NAME INITIAL(OPTIONAL) LAST NAME

Present Address

ADDRESS LINE 1 ADDRESS LINE 2 CITY STATE ZIPCODE

Permanent Address (Skip if same as Present Address)

ADDRESS LINE 1 ADDRESS LINE 2 City STATE ZIPCODE PHONE EMAIL

Personal Information

Are You a citizen or do you have authorization to work in the United States? YES NO Have you applied to this school before? YES NO Which starting month are you applying for? JANUARY JUNE WHICH STARTING YEAR ARE YOU APPLYING FOR?

yyyy format

Personal Statement

WHY HAVE YOU CHOSEN A CAREER IN MEDICAL LABORATORY SCIENCE?*

Employee Record 1

COMPANY FROM DATE (MM/DD/YYYY) TO DATE (MM/DD/YYYY) SUPERVISOR POSITION COMPANY ADDRESS CITY STATE ZIPCODE REASON FOR LEAVING

Employee Record 2

COMPANY FROM DATE (MM/DD/YYYY) TO DATE (MM/DD/YYYY) SUPERVISOR POSITION COMPANY ADDRESS CITY STATE ZIPCODE REASON FOR LEAVING

Education Record 1

SCHOOL/COLLEGE NAME* SCHOOL/COLLEGE ADDRESS CITY STATE ZIP CODE GRADUATION DATE (MM/DD/YYYY) DEGREES HOURS OF CREDIT

Education Record 2

SCHOOL/COLLEGE NAME SCHOOL/COLLEGE ADDRESS CITY STATE ZIP CODE GRADUATION DATE (MM/DD/YYYY) DEGREES HOURS OF CREDIT

Education Record 3

SCHOOL/COLLEGE NAME SCHOOL/COLLEGE ADDRESS CITY STATE ZIP CODE GRADUATION DATE (MM/DD/YYYY) DEGREES HOURS OF CREDIT

Education Status

Will you have your bachelor's degree prior to entering the medical laboratory science program? YES NO Are there any courses that do not appear on your transcript that you will be taking prior to entering the medical technology program? YES NO IF YES, LIST THOSE COURSE(S) AND EXPECTED COMPLETION DATE(S).

Additional Information

Have you ever been convicted of an offense other than a minor traffic violation? YES NO IF YES, PLEASE DESCRIBE THE OFFENSE(S) AND DATES.

Extracurricular Activities

LIST HOBBIES/INTERESTS, AWARDS, COLLEGE ORGANIZATIONS, ETC

Application Affidavit / Terms and Conditions

I UNDERSTAND THAT IN ORDER FOR MY APPLICATION FILE TO BE COMPLETE I MUST SUBMIT THIS APPLICATION, OFFICIAL TRANSCRIPTS AND/OR EVALUATIONS FROM THE COLLEGES AND UNIVERSITIES I HAVE ATTENDED, AND 3 LETTERS OF RECOMMENDATION. I HEREBY CERTIFY THAT ALL OF THE INFORMATION LISTED ON THIS FORM IS TRUE AND COMPLETE. I UNDERSTAND THAT ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION GIVEN BY ME ON THIS APPLICATION IS SUFFICIENT CAUSE FOR REJECTION. I ALSO UNDERSTAND AND AGREE THAT ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION DISCOVERED ON THIS APPLICATION AT ANY TIME AFTER I BEGIN THE MEDICAL TECHNOLOGY PROGRAM MAY RESULT IN MY DISMISSAL. * I HAVE READ AND CONSENT TO THE TERMS AND CONDITIONS OF THE APPLICATION IN ITS ENTIRETY. I FURTHER RECOGNIZE THAT TYPING MY NAME IN THE BOX BELOW CONSTITUTES MY ELECTRONIC SIGNATURE TO THIS AGREEMENT*

Type your full name as your electronic signature

Medical Laboratory Science

Medical Laboratory Science Online Application

School MLS Application