VANDERBILT UNIVERSITY MEDICAL CENTER
PROGRAMS IN ALLIED HEALTH
Program of Medical Laboratory Science
APPLICATION FOR ADMISSION
PERSONAL INFORMATION:
Full Name: ____________________________________________________________________
Last
First
MI.
Social Security Number:
_________________________________________________________
Present Address: ________________________________________________________________
(Street, apartment #, etc.)
___________________________________________________________________
(City)(State)(Zip)
Telephone Numbers: _____________________________________________________________
Home
Cell
Fax
E-mail: _______________________________________________________
Permanent Address: _____________________________________________________________
________________________________________________________________________________
City
State
Zip
OPTIONAL INFORMATION:
Date of Birth ______________________Birthplace________________________________
Citizenship: _______________________________________________________________
Marital Status: ______________________No. of Children and Ages __________________
Spouse’s Name ___________________________________________________________
Spouse’s Address if different _________________________________________________
Attach a clear, passport-sized photograph with name on the reverse side.
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EDUCATIONAL BACKGROUND:
List all colleges and professional schools attended.
Please have official transcripts sent from all colleges and professional schools attended to the address
at the end of the application.
School
City
Dates
attended
Degree
earned
ACADEMIC HONORS/MEMBERSHIP IN PROFESSIONAL ORGANIZATIONS:
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
PROFESSIONAL OR EMPLOYMENT EXPERIENCE:
Position
Employer
Address
Dates
2
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COMMENTS:
Indicate any special experience or qualification not covered in this form.
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
GOALS:
Briefly describe your goals in pursuing a career in medical laboratory science.
(Attach additional sheets if necessary)
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
REFERENCES:
Please submit the names and addresses of three professionals who are acquainted with your academic
and/or professional experience and your personal character. Please have the enclosed reference forms
completed and returned to the address listed or have a Pre-Professional Evaluation Form from your
college or university sent to the address listed.
Name
1)
Address
City
Zip
Numbers
PHONE:
FAX:
2)
PHONE:
FAX:
3)
PHONE:
FAX:
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If accepted as a student in the Vanderbilt University Medical Center Program of Medical
Laboratory Science, I agree to abide by the rules and regulations of the program.
____________________________________________________________________________________________
SIGNATURE OF APPLICANT:
DATE:
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PLEASE SEND ALL CORRESPONDENCE TO THE FOLLOWING ADDRESS:
Program of Medical Laboratory Science
Vanderbilt University Medical Center
4605 The Vanderbilt Clinic
1301 Medical Center Dr.
Nashville, Tennessee 37232-5310
Telephone:
Fax:
(615) 322-8681
(615) 343-8420
E-mail: holly.j.irby@vanderbilt.edu
NON-DISCRIMINATION POLICY STATEMENT
In compliance with federal law, including the provisions of Title IX of the Education
Amendments of 1972, Sections 503 and 504 of the Rehabilitation Act of 1973, and the
Americans With Disabilities Act of 1990, Vanderbilt University does not discriminate on the
basis of race, sex, religion, color, national or ethnic origin, age, disability, or military service in
its administration of educational policies, programs or activities; its admissions policies;
scholarship and loan programs; athletic or other University-administered programs; or
employment. Inquires or complaints should be directed to the Opportunity Development
Officer, Baker building, Box 1809 Station B, Nashville, TN 37235. Telephone (615) 3224705 (VITDD); fax (615) 421-6871.
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