Medical Laboratory Technician
Program Application
Full Name First Name
Gender
Male
MI
Female
Last Name
Maiden Name
Panola College Student ID (If Applicable)
Address Street Address
City
Email
State Zip
Phone ( )
Semester You are Applying for
Fall
Alt. Phone ( )
-
Spring YEAR
Have you applied to the Panola MLT program before?
Are you a Registered Phlebotomist?
-
Yes
Yes
No
No If yes, Please list agency of registry below:
Phlebotomy Registry Agency?
Part I- EducationList 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!”
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- CompositionWrite 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
______________________________________
Program Director
______________________
Date