Full Name First Name MI Last Name Maiden Name

Medical Laboratory Technician

Program Application Full Name First Name MI Last Name Maiden Name Gender Male Female Panola College Student ID (If Applicable)

Address Street Address City State Zip Email Phone ( ) - Alt. Phone ( ) - Semester You are Applying for Fall Spring YEAR

Have you applied to the Panola MLT program before? Yes No

Are you a Registered Phlebotomist? Yes No If yes, Please list agency of registry below:

Phlebotomy Registry Agency? Part I- Education- List all colleges attended College- Full Name City and State Dates Attended

Check each level of education you have completed: GED High School Diploma AA Degree Other (please specify) list other education

Part II- Checklist Complete EACH of the following steps to insure you receive proper credit and your enrollment is secured! You need to have these complete or “in the works!” Medical Laboratory Technician

Program Application Complete application and email back to Program Director.

A copy of all unofficial transcripts from OTHER colleges (if applicable) sent to the Program Director (to get credit for courses taken at other colleges). Apply for admission to Panola College online at www.panola.edu.

Official transcripts from all colleges and universities must be sent directly from issuing institution(s) and officially evaluated by the Panola College. YOU must call and request these copies be sent to Panola!

Part III- Composition- Write a 3 brief paragraphs explaining why you would like to become an MLT, what you THINK MLTs do, and how being an MLT fits into your future career goals. Type your paragraphs here

Part IV- Certification I certify that: 1. All information provided in this application is true and complete. This application has been initially submitted and signed electronically. This application will be printed and signed by me personally upon my first meeting with the program director. 2. It is my responsibility to provide all requested information to complete my file. Failure to provide all requested information may adversely affect my evaluation. 3. Admission to the program is conditional until all requirements have been satisfactorily completed. 4. I understand and agree to actively participate in the learning process as required.

Electronic Signature of Applicant- Type Full Name Date of Electronic Signature

______Signature of Applicant Date Medical Laboratory Technician

Program Application ______Program Director Date