Dear Prospective Phlebotomy student:
Thank your interest in the Phlebotomy Technician Program at Luzerne County Community College.
We are pleased to provide you with the information you requested.
In order to register for this program, you need to complete all the attached paperwork in this packet, and
then call 1-800-377-5222 extension 7495 with your credit card or in person with full payment. Class
size is limited. Registrations will be taken on a first come, first served basis.
In addition to any other academic and non-academic requirements mandated by College policy, students
must also receive satisfactory clearance on the following background checks in order to be accepted into
LCCC’s Phlebotomy Program: Pennsylvania (PA) criminal background check; PA Child Abuse
background check; 10-panel drug screening; FBI fingerprint-based background screening; Office of
Inspector General background screening for suspension or disbarment from Federal Programs; and
Department of Motor Vehicle driver license screening for any prior or current history of DUI (Driving
Under the Influence).
Notification of satisfactory clearance of all screenings must be completed prior to acceptance into the
LCCC Phlebotomy Program. A satisfactory clearance means no criminal history. If any of the abovenoted background checks indicate any criminal history, the student will be prohibited from entrance into
the LCCC Phlebotomy Program.
The book will be available one to two weeks prior to the beginning of the class at the LCCC Bookstore
in the Campus Center. The bookstore (1-800-377-5222 extension 7434) can mail the course book to you
for a fee.
Upon successful completion of the program, students may elect to sit for the National Healthcareer
Association (NHA) certification exam for phlebotomists (CPT). Information about this exam will be
provided to students wishing to pursue this certification as they proceed through the program.
If you have any questions, please call 1-800-377-5222 extension 7495 or email coned@luzerne.edu.
Rev 9-11
PHLEBOTOMY CHECKLIST
Information on forms attached to be completed
1. _____Registration Form - to be completed by student and returned to Continuing
Education with $1195.00 check, money order, or credit/debit card payment.
2. _____Emergency Contact Information – to be completed, signed, dated by student
and returned to Continuing Education.
3. _____Family Medical History – to be completed by student and returned to
Continuing Education.
4. _____Physician Physical Form – to be completed, signed, dated by physician and
returned to Continuing Education.
5. _____Medical Health Form Immunization Record – to be completed, signed dated
by physician and returned to Continuing Education.
6. _____10 Panel Drug Screen (Urine) – Contact Program Coordinator for details.
Cost is $52.00.
7. _____PA Child Abuse History Clearance – to be completed and mailed to the
address on the top of the form with a $10.00 money order made payable to
Department of Public Welfare.
8. _____PA Request for Criminal Record Check – to be completed and returned to
Continuing Education with $10.00 cash, check, or money order made payable
to LCCC Department 63,000.
9. _____FBI Finger-Print Based Criminal Record Check – Directions included in
packet. Cost is $38.50.
10. _____Request for Driver Information (DL-503) – to be completed and mailed to the
address on the top of the form with a $5.00 check or money order made payable
to PennDOT. If you have a credit card or debit card you can process the request
on-line at www.dmv.state.pa.us.
11. _____Student Code of Conduct/Rules and Regulations - to be read, signed, dated
by student and returned to Continuing Education.
12. _____Cancellation and Refund Policy - to be read, signed, dated by student and
returned to Continuing Education.
13. _____Health Insurance Form – – to be completed by student and returned to
Continuing Education.
14. _____Professional Liability Insurance Program for Individual Students – to be
completed and mailed with a $ 35.00 check or money to address on back of
application. If you have a credit card or debit card you can process the
application on-line at www.proliability.com.
15. _____Proof of High School completion (copy of diploma or GED)
16. _____Proof of Age (copy of driver’s license or birth certificate)
17. _____Book available at College Bookstore
ALL INFORMATION MUST BE RETURNED TO:
CONTINUING EDUCATION DEPARTMENT
EDUCATIONAL CONFERENCE CENTER, BLDG 10
LUZERNE COUNTY COMMUNITY COLLEGE
1333 S PROSPECT ST
NANTICOKE PA 18634
Make checks payable to Luzerne County Community College Dept. 63000
Continuing Education Department
Name: ___________________________________________Social Security # _______________
Address: ______________________________________________________________________
City: _________________________ State: ______________________ Zip: _______________
Day Phone: _________________________ Eve. Phone: ________________________________
E-Mail: _____________________________Date of Birth _______________________________
I am paying by:
Check No. _______ Visa ____ MC ___ Discover ____ Other ________
Cardholder’s Name: _____________________________________________________________
Card Number: ____________________________________________Exp. Date: ____________
3-Digit ID Code (found on signature strip on back of card) ____________________________
Signature: _____________________________________________________________________
The information for the following questions are required for state and federal statistical purposes only.
Responses will not be used to determine admission.
Ethnicity: (Select one)
Gender: _______Male _______Female
Hispanic or Latino
Not Hispanic or Latino
Race (Select one or more)
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Are you a citizen of the United States? Yes___ No ___ (If no, then please complete next four items)
1. Country of citizenship: _____________________________________________
2. Permanent Resident Card #: ________________________________________
3. Foreign Student (F1 Student Visa #): __________________________________
4. Other Visa (Please list type and #): ___________________________________
Course Name
Location Day (s)
Begin
Date
End Date Time
Tuition
1333 South Prospect St. Nanticoke PA 18634, Tel: 1-800-377-5222 extension 7495 Rev 9-11
Emergency Contact Information
Luzerne County Community College
1333 South Prospect Street
Nanticoke, PA. 18634-3899
To be completed by student prior to physician examination
__________________________________________________________
Last
First
Middle
(Maiden)
__________________________________________________________
Address
City
State
Zip
__________________________________________________________
Home Phone
Alternate Number
__________________________________________________________
Social Security Number
Date of Birth
Sex M/F
__________________________________________________________
Employers Name
Employers Address
__________________________________________________________
Emergency Contact Name
Relationship
__________________________________________________________
Emergency Contact Address
Phone Number
I give permission to the Luzerne County Community College Continuing Education Department to release any or /all
information concerning my application and health status to those clinical sites which require such information. I fully
understand the nature of this consent and that this authorization shall remain effective from the date of my signature to
one year hence: however, I may revoke this authorization at any time by written, dated communication to Luzerne
County Community College.
If I, or the next of kin/family member cannot be reached at the time of an emergency, Luzerne County Community
College may send me to the hospital or physician most readily accessible and /or administer necessary emergency
care. Luzerne County Community College may have access to information regarding my health or medical status.
I hereby release Luzerne County Community College from all legal responsibility and liability for acting upon this
authorization, and I intend to be legally bound hereby.
I agree to notify the Luzerne County Community College Continuing Education Department of any change in my
health status within two weeks.
STUDENT SIGNATURE_________________________________________DATE____________________
Rev 9-11
Family Medical History
Luzerne County Community College
Name
Age
State of
Health
Occupation
Age at
death
Cause of Death
Father
Mother
Brothers
Sisters
Have any of your relatives ever had any of the following:
Yes
No
Relationship
Tuberculosis
Diabetes
Kidney disease
Heart disease
Arthritis
Stomach disease
Asthma
Epilepsy/Seizures
Have you had any of the following?
Yes
No
Yes
Measles
German Measles
Sinusitis
Vision Problems
Mumps
Chicken pox
Malaria
Anxiety/Depression
Ear, Nose, or Throat
Gum/Tooth Disease
Insomnia
Chest Pain
Chronic Cough/Frequent
Colds
Heart Palpitations
Headaches
Epilepsy
Head Injury with
Unconsciousness
High/Low Blood Pressure
Asthma/Hay Fever
Tuberculosis
Shortness of Breath
Rheumatic Fever
Heart Murmur
Disease or injury to joints
Back Problems
Recurrent Diarrhea
Hepatitis/Jaundice
Intestinal/Stomach Problems
Gallbladder Disease
Recent weight
loss/gain
Hernia/Rupture
Paralysis/Weakness
Frequent Urination
Rev 9-11
Dizziness/Fainting
No
Tumor, Cancer,
Cyst
Blood disorders
Physician Physical Form
Luzerne County Community College
Last Name
(please print)
First
Blood Pressure:
Pulse/Resp:
Height
Allergies:
Hearing:
Current Medications:
Musculoskeletal:
Ears, Nose, Throat:
Metabolic/Endocrine:
Eyes :
Neurological:
Cardiovascular:
Psychiatric:
Genitourinary:
Skin:
Is there any physical defect which would limit the
student’s participation in classroom/clinical?
Is there loss or seriously impaired function of any
paired organs?
Is there any mental, emotional or physical
condition of a privileged nature for which the
student should remain under periodic
observation?
Does the student have any medical problems with
which the college should be concerned?
Recommendations for physical activity
limited
unlimited
Do you have any recommendations regarding the
care of this student?
Is the student now under any treatment for any
emotional conditions
If yes to any of the above questions please explain
Weight
PHYSICIAN SIGNATURE__________________________________DATE_____________________
Rev 9-11
Medical Health Form Immunization Record
Luzerne County Community College
Name: ________________________________ Date_______________________
Tetanus
Date of last
immunization:
(Booster given every ten years)
10 Panel drug screening
Please attach copy of results to this
form
Measles/Mumps/Rubella
Varicella Immunization
Date:
Date:
If dates are unknown, you must have
a blood titer drawn showing proof of
immunity and a copy of the results
must be attached to this form
Hepatitis B Vaccine
*Student must provide documentation
of the first two injections before
clinical experience commences
Or Titer results:
Dates of immunization:
#1.________
#2.________
#3.________
Tuberculosis Testing
Tuberculin (TB) Skin Test : PPD via Mantoux Technique
Step One
Step Two
Date: _____________________
Date: _____________________
Left Arm
Right Arm
Administered by: ______________
Read in 48-72 hours after injection
Date Read:___________________
Read By: ____________________
Reading Results:
Negative
Positive
Description of Reaction:___________
Left Arm
Right Arm
Administered by:_______________
Read in 48-72 hours after injection
Date Read: ___________________
Read By: ____________________
Reading Results:
Negative
Positive
Description of Reaction:___________
*After the first application of the two step has been administered, give the second portion
1-3 weeks later. If the patient has had a two step prior, and has proper documentation
with consistent yearly PPD documentation, then only a year PPD testing is required.
Please be advised this is a mandatory requirement for all Health Science
Students participating in clinical experience to have a Two Step Mantoux Testing.
Rev 9-11
PENNSYLVANIA CHILD ABUSE HISTORY CLEARANCE
CHILDLINE USE ONLY
COMPLETE SECTION I ONLY. PRINT CLEARLY IN INK. ENCLOSE $10.00 MONEY ORDER
ONLY. PAYABLE TO DEPARTMENT OF PUBLIC WELFARE. DO NOT SEND CASH OR
PERSONAL CHECK.
DATE RECEIVED BY CHILDLINE
SEND TO CHILDLINE AND ABUSE REGISTRY, DEPARTMENT OF PUBLIC WELFARE,
P.O. BOX 8170 HARRISBURG, PA 17105-8170
APPLICATIONS THAT ARE INCOMPLETE ILLEGIBLE OR RECEIVED WITHOUT FEE WILL
BE RETURNED UNPROCESSED. IF YOU HAVE QUESTIONS CALL 717-783-6211
APPLICANT IDENTIFICATION
SECTION I
IN THIS SPACE PRINT APPLICANTS FULL NAME AND ADDRESS (DO NOT USE INITIALS)
SOCIAL SECURITY NUMBER
NAME
STREET
AGE
CITY, STATE
ZIP CODE
DATE OF BIRTH
DAYTIME PHONE NO.
COUNTY YOU LIVE IN
SEX
M
F
PREVIOUS NAMES USED SINCE 1975 (Include Maiden Name, Nicknames, Aliases)
(FIRST, MIDDLE, LAST)
(FIRST, MIDDLE, LAST)
PURPOSE OF CLEARANCE (Check ONE block ONLY)
CHILD CARE
VOLUNTEERS-A copy of your PROCESSED 'Request
for Criminal Record'' (Form SP4-164) must be
attached. Out-of-state residents must also attach a
copy of their PROCESSED FBI clearance (Form
FID-258).
FOSTER CARE
ADOPTION
SCHOOL
CWEP (Community Work Experience Program
Participant)
SIGNATURE OF CAO REP
CAO PHONE NO
PREVIOUS ADDRESSES SINCE 1975 (Attach additional pages if necessary)
1.
2.
3.
4.
HOUSEHOLD MEMBERS (List everyone who lived with you at anytime since 1975 to the present).
NAME (First, Middle, Last) Do not use initials.
RELATIONSHIP
PRESENT
AGE
SEX
1.
2.
3.
4.
5.
6.
I certify that the above information is accurate and complete to the best of my knowledge and belief and submitted as
true and correct under penalty of law (Section 4904 of the Pennsylvania Crimes Code).
Applicants are required to show the Administrator the original
document. Administrators are required to keep a copy of this
child abuse history record on file. Any person altering the
contents of this document may be subject to civil, criminal or
administrative action.
APPLICANT'S SIGNATURE
DO NOT WRITE IN THIS SECTION
SECTION II
CHILDLINE USE ONLY
RESULTS OF HISTORY CHECK
APPLICANT IS NOT LISTED IN A REPORT OF CHILD ABUSE
OR A REPORT FOR SCHOOL EMPLOYEE.
STATUS OF REPORT
APPLICANT IS LISTED IN A REPORT OF CHILD ABUSE OR A
REPORT FOR SCHOOL EMPLOYEE (SEE BELOW).
DATE OF INCIDENT
STATUS OF REPORT
1.
3.
2.
4.
VERIFIER
03460C
-
DATE
DATE
VERIFIER'S SUPERVISOR
DATE OF INCIDENT
DATE
CY 113
12/99
DO NOT WRITE IN THIS SECTION - CHILDLINE USE ONLY
VOLUNTARY CERTIFICATION FOR CHILD CARE SERVICES
SECTION III
has requested a certification which includes a clearance of
his/her name against the child abuse, school employee, and criminal history reports.
The results of the child abuse and school employee report clearances are listed in Section II on the
reverse side. The results of the criminal history reports are listed below. Out-of-state residents
must have criminal history clearance from both the Pennsylvania State Police and the FBI. The
voluntary certification may be obtained every two years.
It is the responsibility of parents and guardians to review this information to determine the
suitability of the applicant as a substitute caregiver.
PENNSYLVANIA CHILD ABUSE HISTORY CLEARANCE
Applicant is named as the perpetrator of a ''Founded'' child abuse or school employee report
which occurred in the last five years.
Applicant is named as the perpetrator of a ''Founded'' child abuse or school employee report
which occurred over five years ago.
Applicant is named as the perpetrator of an ''Indicated'' child abuse or school employee report.
Applicant is not named as the perpetrator of any child abuse or school employee report
contained in the Statewide Central Register.
PENNSYLVANIA STATE POLICE CLEARANCE
Record exists and contains convictions which prohibit hire in a child care position. Report
attached.
Record exists, but convictions do not prohibit hire in a child care position. Report attached.
Record exists, but no convictions are shown. This does not prohibit hire in a child care
position. Report attached.
No record exists. Report attached.
FBI CLEARANCE
Record exists and contains convictions which prohibit hire in a child care position. Report
attached.
Record exists, but convictions do not prohibit hire in a child care position. Report attached.
Record exists, but no convictions are shown. This may not prohibit hire in a child care
position. Report attached.
No record exists. Report attached.
No FBI clearance required.
VERIFIER
034600
DATE
VERIFIER'S SUPERVISOR
DATE
CY 113 - 12/99
SP 4-164 (12-99)
FOR CENTRAL REPOSITORY USE ONLY
PENNSYLVANIA STATE POLICE
(LEAVE BLANK)
REQUEST FOR CRIMINAL RECORD CHECK
DATE OF REQUEST
PART I: TO BE COMPLETED BY REQUESTER
(INFORMATION WILL BE MAILED TO REQUESTER ONLY)
*** TYPE OR PRINT LEGIBLY WITH INK ***
NOTE:
IF THIS FORM IS NOT LEGIBLE OR NOT PROPERLY COMPLETED, IT WILL BE RETURNED UNPROCESSED TO THE
REQUESTER. A RESPONSE MAY TAKE THREE WEEKS OR LONGER TO PROCESS.
WARNING!
A PERSON COMMITS A MISDEMEANOR OF THE THIRD DEGREE IF HE/SHE MAKES A WRITTEN FALSE
STATEMENT, WHICH HE/SHE DOES NOT BELIEVE TO BE TRUE.
ADDRESS
Susan Spry
Luzerne County Community College
Continuing Education Office
Luzerne County Community College
1333 South Prospect Street
CITY
Nanticoke
STATE
ZIP
PA
18634
CONTACT TELEPHONE NUMBER INCLUDING AREA CODE
-
-
0 4 9 5
9 FOR REQUEST (CHECK ONE BLOCK)
REQUESTER IDENTIFICATION (ONLY CHECK ONE BLOCK)
7
 INDIVIDUAL/NONCRIMINAL JUSTICE AGENCY – ENCLOSE A CERTIFIED CHECK/MONEY ORDER or Cash IN THE AMOUNT OF $10.00 PAYABLE TO LCCC
5 7 0
REASON
7 4 0
THE FEE IS NONREFUNDABLE

*** DO NOT SEND CASH OR PERSONAL CHECK ***
FEE EXEMPT NONCRIMINAL JUSTICE AGENCY
NAME/SUBJECT OF RECORD CHECK
MAIDEN NAME AND/OR ALIASES



(LAST)
(FIRST)
SOCIAL SECURITY NUMBER (SOC)
EMPLOYMENT (IF APPLICABLE, CHECK ONE OF THE FOLLOWING)

ELDER CARE
(MIDDLE)
DATE OF BIRTH (DOB)

SEX
CHILD CARE
RACE

SCHOOL DISTRICT
ADOPTION/FOSTER CARE
OTHER CIRCLE Nurse Aide ___Phlebotomy___ EKG_________________________________
ONLY CHECK THIS BLOCK IF YOU WANT TO REVIEW YOUR ENTIRE CRIMINAL HISTORY

INDIVIDUAL ACCESS AND REVIEW OR FIREARMS CHALLENGE-ENTIRE CRIMINAL HISTORY
(AVAILABLE ONLY TO SUBJECT OF RECORD CHECK OR LEGAL REPRESNETATIVE WITH LEGAL AFFIDAVIT OF LEGAL REPRESENTATIVE ATTACHED)
REQUESTER CHECKLIST
AFTER COMPLETION MAIL TO:
Joanne Kohler
DID YOU ENTER THE FULL NAME, DOB AND SOC?
DID YOU ENCLOSE THE $10.00 FEE (CERTIFIED CHECK/MONEY ORDER)?
*** DO
Continuing Education Office
Luzerne County Community College
1333 South Prospect Street
Nanticoke, PA 18634
NOT SEND CASH OR PERSONAL CHECK ***
DID YOU ENTER YOUR COMPLETE ADDRESS INCLUDING ZIP CODE AND
TELEPHONE NUMBER IN THE BLOCKS PROVIDED?
PART II: CENTRAL REPOSITORY RESPONSE ONLY
INFORMATION DISSEMINATED

NO RECORD

INQUIRY DISSEMINATED BY
NAME
DATE OF BIRTH
SEX



SID NUMBER
CRIMINAL RECORD ATTACHED
THE INFORMATION DISSEMINATED BY THE CENTRAL REPOSITORY IS BASED ON THE
FOLLOWING IDENTIFIERS THAT MATCH THOSE FURNISHED BY THE REQUESTER.



*** DO NOT WRITE BELOW THIS LINE ***
CERTIFIED BY
SOCIAL SECURITY NUMBER
RACE
MAIDEN/ALIAS NAME
(DIRECTOR, CENTRAL REPOSITORY)
This response is based on a comparison of data provided by the requester in Part I against the information contained in the files of the Pennsylvania
State Police Central Repository only, and does not preclude the existence of criminal records which might be contained in the repositories of other
local, state, or federal criminal justice agencies.
TO BE ENROLLED IN THE PROGRAM, THE CRIMINAL BACKGROUND CHECK MUST COME BACK APPROVED
BY THE STATE POLICE.
Revised 07/19/2011
Mandatory for All Health Science Students
FBI Finger-Print Based Criminal Record Check
Please follow the instructions below to acquire your FBI Finger- Print
Based Criminal Record Check
1. To begin please register online go to: www.pa.cogentid.com
2. Click on the Department of Education and follow the step by step instructions. Payment methods can
be done with a credit card or you must hand carry a money order the day of your appointment.
3. After the registration is completed, print out the required page. You also have the option to have the
results mailed directly to you which is an additional fee.
4. Set up an appointment for the finger printing process. Check the website for the location closest to
you. Be sure to take along the required printed page and your money order if you chose that method of
payment.
5. Once you have completed the finger printing process they will issue you a form with instructions to
follow to retrieve your results in 24 – 48 hours. Please be sure you have the ability to print out your
results unless you chose to have your results mailed directly to you.
6. Please be sure to make a copy of the results and include them with the all of the other forms necessary
to start the program.
Any questions please feel free to contact the Continuing Education Department at 1-800-377-5222
extension 7495 or via email coned@luzerne.edu.
Rev 9-11
DL-503 (7-11)
INSTRUCTIONS
1. To request your own record, complete Sections A & C only. Notarization is NOT required.
2. To request a record other than your own, complete Sections A, C, and D. Section E must contain the driver's signature if block
B, E or L is checked in Section D. If the Requester is obtaining the information on behalf of someone else, Section B
must also be completed.
3. Print or type all requested information on the front of the form. Submitting ONLY a name and address does not provide
enough information for a proper search of the driver files.
4. A non-refundable fee is required for each request. If the Bureau has no record for the information requested or the data supplied
is insufficient, the fee will be applied to the cost of the search.
5. If requesting a microfilm copy of a document, also complete Section F. You must be specific in providing the type and date of the document. If there are several citations on the record, the cost is $5.00 per citation. You need to provide the date of the
violation/action to clearly identify the citation(s) requested.
6. Check the type of record requested at the top of the form and make check or money order payable to "PennDOT." DO NOT SEND CASH. Attach your check or money order and send to:
For overnight and other special mail:
Bureau of Driver licensingBureau of driver licensing
Driver record servicesdriver record services
p.o. box 68695
1101 south front street 3rd floor
harrisburg, pa 17106-8695
harrisburg pa 17104-2516
DESCRIPTION OF INFORMATION AVAILABLE
Basic Information��������� Includes name, address, driver number, date of birth and class of license.
($5.00 fee)
3 year record*�������������� Includes name, address, driver number, date of birth, class, license status, Departmental actions and violations for the
past 3 years from the date request is processed. You can obtain a copy of your own record on PennDOT's website at
($5.00 fee)
www.dmv.state.pa.us
10 year record*������������ Includes name, address, driver number, date of birth, class, license status, Departmental actions and violations for the
past 10 years from the date request is processed. A 10-year record is for employment purposes only. You can obtain a
($5.00 fee)
copy of your own record on PennDOT's website at www.dmv.state.pa.us
FULL HISTORY������������������� Includes name, address, driver number, date of birth, class, license status, Departmental actions and violations for the
complete history of the driver on file in Pennsylvania.
($5.00 fee)
Certified Record���������� Includes name, address, driver number, date of birth, class, license status, Departmental actions and violations for the
complete history of the driver on file in Pennsylvania certified by the Department.
($10.00 fee)
MICROFILM
DOCUMENT������������������������ Copies of documents retained by the Department are available for purchase from the microfilm file. You must be specific
as to the type of document and the date of the violation/action.
($5.00 fee)
Certified copy
of document������������������ Copies of documents from the microfilm file that have been certified by the Department.
($10.00 fee)
IMPORTANT INFORMATION CONCERNING THE USE OF DRIVER INFORMATION
• Driver record information is confidential and restricted information and the Requestor/End User is responsible for establishing procedures to protect the confidentiality of these records.
•
Driver record information can only be used for the purpose stated in Section D.
•
PennDOT retains exclusive ownership of all driver record information and the Requestor/End User shall not combine and/or link in with any other data on any database except as may be required by law.
•
The driver record information cannot be disseminated or published on the Internet without the express written permission of PennDOT.
•
•
Driver record information cannot be sold, assigned, or otherwise transferred to any party, other than the End User.
The driver record information cannot be used for direct mail advertising or any other type or types of mail or mailings.
• PennDOT reserves the right to audit each request for driver record information. If the Requestor/End User is found to have requested driver record information for an unauthorized purpose, access to Pennsylvania driver record information will be terminated.
*Businesses who obtain driver records for the purpose of employment or insurance are now able to obtain and print these records,
in real time, through our enhanced Online Services.
If you are an employer or insurance company/agent and are interested in becoming an authorized Online business user, please
visit our website at www.dmv.state.pa.us and click on "Online Business Services" for more information.
DL-503 (7-11)
request for driver information
The most current version of this form can be found at www.dmv.state.pa.us
PLEASE TYPE OR PRINT IN BLUE OR BLACK INK
DO NOT SEND CASH • see reverse for instructions
D E PA R T M E N T O F T R A N S P O R TAT I O N
CHECK (✔) ONE ONLY:
❑BASIC INFORMATION: $5.00 FeE (Driver history is not included)
❑ 3 YEAR Driver RECORD: $5.00 Fee
Bureau of Driver Licensing
P.O. Box 68695
Harrisburg, PA 17106-8695
❑ Full History: $5.00 Fee
❑ CERTIFIED DRIVer RECORD: $10.00 Fee
❑Copy of document from file (microfilm): $5.00 Fee
❑CERTIFIED COPY OF document from file: $10.00 Fee
❑ 10 YEAR Driver RECORD: $5.00 Fee (Employment Purposes Only)
You may obtain a copy of your own 3 year, 10 year and/or Full History Driving Record on PennDOT'S website at www.dmv.state.pa.us
A REQUESTER INFORMATION
B END USER OF INFORMATION being requested
NAME/company
name/company
ADDRESS
address (P.O. Box not acceptable), need to provide physical location of business/residence
CITY STATE ZIP CODE city state zip code
DAYTIME TELEPHONE number (required) ________________________________________________
DAYTIME TELEPHONE number (required) ________________________________________________
_
relationship to driver (required)_________________________________________________ relationship to driver (required)__ _______________________________________
D AFFIDAVIT OF INTENDED USE
signature
Intended Use of the Information Requested: CHECK ONLY ONE X
❏ B = Driver Release (Driver must complete Section E.)
❏ C = Credit Business (Legitimate Business need in connection with a business
❏ C = Credit Potential Investor, Server or Current Insurer (In connection
ADDRESS
❏
CITY
❏
NOTARIZATION NOT REQUIRED WHEN REQUESTING YOUR OWN RECORD
C DRIVER INFORMATION
NAME:LAST
FIRST
STATE
INITIAL
ZIP CODE
transaction initiated by the driver.)
❏
❏
phone number
date of birth
MONTH
DRIVER NUMBER
DAYYEAR
E driver release
I________________________________________ hereby request
name of driver
the Department of Transportation to furnish a copy of my PA Driver's
Record to_____________________________________________ X
name of person/company
signature of driverdate
F microfilm
TYPE OF DOCUMENT
date of violation
with an assessment of the credit/payment risks associated with an existing
credit obligation.)
E = Employment (To support the hiring or the continuation of employment.
Driver must complete Section E.)
R = Insurance Company requesting record of person it intends to insure,
now insures, or has rejected for insurance.
K = Court Order must be attached. (A subpoena issued in compliance
with Pa. R.C.P. 4009.21 will be accepted in lieu of a court order).
L = Attorney representing driver identified in Section C (Driver must
complete Section E.)
I hereby Certify that________________________________________________
PRINTED NAME OF REQUESTER
will use the driver record abstract(s) required pursuant to Section 6114
of the Pennsylvania Vehicle Code, for the purpose checked above only
and no other reason. This affidavit is filed in compliance with Section
607 of the Fair Credit Reporting Act. I/We have read and signed this
form after its completion, and I/We swear or affirm that the statements
made herein are true and correct, and that any statement made on or
pursuant to this form is subject to the penalties of 18 Pa C.S. Section
4903(a)(2) (relating to false swearing), which shall include punishment
of a fine not exceeding $5,000, or to a term of imprisonment of not more
than two years, or both.
X
_______________________________________________________________
SIGNATURE OF REQUESTER
Title____________________________________________________________
SUBSCRIBED AND SWORN
(see list of available documents below)
Documents Available:
• Citations
• Court Certifications
• Applications
• License Renewals
• Judgments
• Suspension Credit Affidavits
• Suspension/Revocation Letters
• Restoration Letters
•Rescind Letters
•Department Hearing or Exam Notice
MESSENGER NO.
NOTARIZATION
TO BEFORE ME:
X
S
E
A
L
MONTH DAYYEAR
SIGNATURE OF PERSON ADMINISTERING OATH
SIGN IN PRESENCE OF NOTARY
Continuing Education Department Career Training Student
Student Code of Conduct/ Rules and Regulations
You are expected to arrive on time, apply full efforts in learning training materials and conduct yourself in a responsible
manner at all times. Any irresponsible, rude, or inappropriate behavior will be cause for dismissal from the school. The
following are considered inappropriate behavior:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
Attendance: You MUST attend the entire program. You are expected to attend and arrive to each class on time. You
must call the instructor prior to the start time of the class, if you will not be in attendance that day. If you are absent
from class more than 3 days, you may be terminated from the program. A doctor’s note will be needed for every absent
day. Eligibility to make up days missed will be at the discretion of the Program Coordinator and/or Associate Dean of
Continuing Education.
If you have notified the instructor of your absence prior to the start time of the class and you need to make up the time to
cover the total hours of the program, you may be charged a fee to cover the added expenses incurred by an instructor
and/or use of equipment (i.e. Nurse Aide). Eligibility to make up days missed will be at the discretion of the Program
Coordinator with approval from the Associate Dean of Continuing Education.
All requests for refunds MUST be submitted in writing, by mail, fax, or in person. The date of receipt in the Continuing
Education office is the date in which we will calculate the refund. Non-attendance does not constitute a withdrawal.
Check the website for details of the current policy but know that if you do not notify the Continuing Education Office in
writing prior to the second day of class.
Smoking in the school building.
Academic dishonesty, including but not limited to, cheating on test, plagiarism, and collusion.
Disruption of the orderly process of the school or interference with school teaching, activities, and functions.
Willful acts of misconduct that may cause damage to the school property, including equipment or that may affect the
safety of state, students, or the general public.
Unlawful manufacture, distribution, dispensing, possession, or use of controlled substances.
Drinking or possession of alcoholic beverages on school grounds.
Unauthorized entry to or use of school property, including the failure to leave school buildings or grounds after being
requested to do so by an authorized employee of the school.
Molestation, assault and battery, threats with bodily harm or conduct that threatens or endangers the health or safety of
any person lawfully on or in the vicinity of school property or at school sponsored or supervised events.
Theft, concealment, defacement or damage of school property or the property of school staff or other students.
Illegal gambling, disorderly conduct, or lewd, indecent, or obscene conduct or expression.
Failure to comply with the reasonable directions of authorized school officials acting in performance of their duties,
including refusing to provide identification upon request.
Illegal or unauthorized possession of firearms, fireworks, explosives, dangerous chemicals, or arms classified as
weapons.
Activities that interfere with the rights of others members of the school community or with normal functions of the
school.
Acts of harassment, written, verbal or physical that stigmatize or victimize an individual on the basis of, but not limited
to, the following: Race, Ethnicity, religion, sex, sexual orientation, creed, national origin, ancestry, age, mental status, or
disability.
It is the responsibility of the student to check the LCCC website at www.luzerne.edu/coned or ask the coordinator for
a copy of the all policies and procedures for attending LCCC Continuing Education programs.
I have read and I understand the LCCC Student Code of Conduct and agree to abide by it.
Class Start Date: __________________________TRAINING PROGRAM: ______________________________
Student PRINT NAME: _____________________________________________________________
Student Signature: ______________________________________________DATE: _____________
Rev 9-11
TITLE: NON-CREDIT CANCELLATION AND REFUND
REF #: 10.1
DATE(S) OF POLICY AND POLICY REVISION APPROVALS: Board approval 2/8/11
Tuition will be refunded 100% for all LCCC non-credit courses canceled by the College. Other refund information varies
dependent upon the course classification.
Tuition for Career Training Courses (will be refunded 100% if withdrawal occurs one week or more before the first class
session. A $50 fee will be deducted from tuition if withdrawal occurs within one week of the first class session and prior to the
second class session to cover registration and administrative fees. No refunds will be given for withdrawals occurring after the
start of the second class session for all career training courses except those for the Nurse Aide program; refunds for the Nurse
Aide program will not be given after the start of the first day of class. .
Tuition for on-line courses will be refunded 100% if withdrawal occurs at least 2 business days (Monday through Friday) prior
to the beginning of the class and/or after receiving access to the course.
All other non-credit programs, courses and trainings (excluding on-line courses): No refund is given for any withdrawals that
occur after the start of the first class session. Cancellation must be made at least 2 business days (Monday through Friday) prior
to the start of the first class.
If the tuition is paid by credit card, the refund will be credited to the customer’s account within one week of the cancelled
course or written withdrawal. Payments made by check or money order will be refunded within 4-6 weeks of the course
cancellation or withdrawal. The refund is paid to payer of record.
Luzerne County Community College reserves the rights to cancel, combine, or divide any programs advertised. Alterations of
the schedule may be necessary due to holidays, weather conditions, school functions, or other conflicts. The College also
reserves the right to make any revision in the curriculum, instructor, tuition and fees, location, or any other phase of activity
necessary without further notice and without incurring obligations.
Due to the structure and content of occupational and professional continuing education courses, some programs/courses may
have deadline dates and different refund policies than those listed here. That information will be provided upon request.
Withdrawals must be submitted in writing; e-mail is acceptable. The date the withdrawal is received by the non-credit office is
the date by which the refund will be calculated. Non-attendance does not constitute a withdrawal.
Note: The word “course” refers to all tuition/fee programs offered through the College.
I, the undersigned have read the above policy and understand how it applies to me:
Print Name: ______________________________________________________________________________
Student Signature ______________________________________ Date: _____________________________
Rev 9-11
STUDENT HEALTH INSURANCE
I acknowledge that as a part of the clinical program education experience, I am required to complete clinical
rotations at a hospital or other healthcare facility. I acknowledge that my attendance at such hospital or other
healthcare facility a participation in a rotation is subject to the rules and regulations of such facility.
Hospitals and other healthcare facilities are requiring, with increasing frequency, that interns and students
maintain adequate health insurance as a condition of participation. By signing below, I acknowledge that I
am responsible for making arrangements and ensuring that I am covered by an adequate health insurance
policy.
I currently have health insurance coverage provided by:
Insurance company name:
Insurance policy number:
By initialing this paragraph, I understand that it is my responsibility to maintain adequate health insurance
throughout the clinical nursing program education experience. In the event my insurance company or
insurance policy number changes during my clinical program education experience, I will promptly notify
Luzerne County Community College.
_______
Initials
I currently do not have any health insurance coverage.
By initialing this paragraph, I understand that it is my responsibility to obtain adequate health insurance
before commencing the clinical program education experience. Once I have obtained adequate health
insurance coverage, I will promptly notify Luzerne County Community College and provide my insurance
company’s name and my policy number.
_______
Initials
By initialing this paragraph, I understand that in the event I require medical care, I shall be fully responsible
for any and all costs incurred with respect to such medical care and agree to indemnify, defend, and hold
harmless Luzerne County Community College and its trustees, officers, agents, and employees from and
against any and all demands, claims, losses and liabilities, including costs and reasonable attorney’s fees,
sought in connection with the provision of such medical care.
_______
Initials
_______________________________________________________
Signature
_______
Date
_______________________________________________________
Printed Name
You must sign and return to the Continuing Education Department.
Rev 9-11
Insurance statement/ask/2010
Professional Liabilit y Insurance Program
for Students
A
P r o f e s s i o n a l
Why You Need Professional Liability Protection
Responsibility. As your student responsibilities increase, so does your chance of
being named in a lawsuit, regardless of the validity of the charges. You are
consistently exposed to clinical settings in which you could be held responsible
for injuries to a patient or fellow student.
Vulnerability. Frivolous and unjustified claims are commonplace in today’s
courts. Professional Liability insurance is a necessary safeguard for any student
healthcare professional.
What Makes Marsh Affinity Group Services Your Best
Choice?
There is nothing more important than finding a reliable company to
administer your insurance program.
More students trust Marsh Affinity Group Services for protection. You will have
peace of mind knowing that Marsh Affinity Group Services is the oldest and
most established insurance administrator for allied professional healthcare
associations and societies. We have worked with allied healthcare schools and
students for over 50 years.
The underwriter of this Program, Chicago Insurance Company, is a member
company of the Interstate National Corporation, one of the Fireman’s Fund
Insurance Companies.
The NATA Student Professional Liability Program
offers you:
A Multiple-Year Certificate Option.
The NATA Program offers a Multiple-Year certificate and an associated premium
credit if you choose to pre-pay. You may choose a 3-year or 2-year certificate. This
option enables you to save money on your premium and gives you peace of mind
knowing your coverage will not lapse from year to year; you may be covered for
your entire educational experience.
Pays Up To $2,000,000/$4,000,000 Professional Liability Coverage.
The insurance company may pay up to $2,000,000 per incident, or up to a total
of $4,000,000 aggregate for covered claims arising from real or alleged negligence.
Few companies offer students limits this high.
Legal Fees Paid in Addition to Liability Limit.
Your legal fees and court costs are paid by the insurance company, for covered
claims, in addition to the limits of liability, even if the suit is groundless, false
or fraudulent.
Administered by:
1440 Renaissance Drive
Park Ridge, IL 60068-1400
1-800-503-9230
www.seaburychicago.com
N e c e s s i t y .
Expert Legal Counsel — At No Cost To You.
With a nationwide network of experienced attorneys and claims adjusters,
immediate support is available to you should a covered claim be threatened
or filed against you. With some other policies, you will have to find your own
legal defense.
School Disciplinary Board/ Grievance Committee Defense.
This insurance policy goes beyond providing protection for your professional
acts as a student healthcare professional. It will reimburse you, up to $1,000
per policy period, for attorney fees and other costs resulting from the
investigation and defense of proceedings before a school grievance committee
or academic disciplinary board if the proceedings result from your provision of
professional services.
Coverages Included At No Additional Cost!
• First Aid Coverage. If you render first aid to others outside of your
educational program and incur expenses, the insurance will reimburse you up
to $500 dollars annual aggregate.
• First Party Assault Coverage. The Program pays up to $1,000 annual
aggregate for medical expenses resulting from bodily injury to you or damage
to your personal property if assaulted. The assault must occur on the school's
premises or the area immediately adjoining such school premises (i.e. the
parking lot), or while you are away from school conducting an authorized
school activity.
Also Includes Supplemental Liability Coverage.
With supplemental liability coverage, subject to the terms of the insurance
certificate, you are covered for bodily injury and property damage occurrences not
related to your professional duties.
You are not covered for engaging in a business or a profession.
Apply Now For This Low-Cost Protection
Your certificate is effective on the date your application and payment are received
and approved in our offices, unless you request a later effective date. Your
effective date may not be earlier than the date the administrator receives and
approves this application. (Do not, however, submit an application more than 90
days prior to the effective date desired.)
Advanced enrollment. To receive your certificate by the date that
verification of insurance is required, we suggest you apply approximately
60 days before that time.
Please allow 3 to 4 weeks for delivery of your certificate.
Underwritten by:
Chicago Insurance Company
Chicago, IL
A member of the Interstate National
Corporation, one of the Fireman’s Fund
Insurance Companies.
This brochure contains a summary
of the program provisions. If there is a
conflict between this brochure and the actual
certificate, the certificate language will
control.
CA-0633005
© Seabury & Smith, Inc. July 2003-
Professional Liabilit y Insurance Program
Student Application
S.C.
NATA/INDVSTUD-L-1M-0703
LICENSED/REGISTERED: If you have passed your licensing examination and are licensed or registered.
DO NOT use the form below. Please contact the Administrator for an appropriate application, indicating your professional status.
Please print and complete both sides of this application.
LAST NAME
FIRST NAME
MIDDLE INITIAL
CITY
STATE
ZIP
SOCIAL SECURITY NUMBER
BIRTHDATE
E-MAIL ADDRESS
DAYTIME PHONE NUMBER
HOME ADDRESS
FULL NAME OF SCHOOL
ADDRESS OF SCHOOL
CITY
STATE
SCHEDULED DATE OF GR ADUATION: MONTH
YEAR
ZIP
PROFESSIONAL LIABILITY INSURANCE PROGRAM — STUDENT APPLICATION
Limits of Liability
$2,000,000 each incident/$4,000,000 aggregate
$1,000,000 each incident/$3,000,000 aggregate
Multiple - Year Certificate Option
$2,000,000 each incident/$4,000,000 aggregate
$1,000,000 each incident/$3,000,000 aggregate
Premium - 1 year
$41.00
$35.00
Premium - 2 years
$80.00
$68.00
Premium - 3 years
$115.00
$ 98.00
I understand that I am not covered by this insurance if I am any of the following: physician, surgeon, dentist, nurse midwife, cytotechnologist,
perfusionist, electroneurodiagnostic technologist, chiropractor, podiatrist, osteopath, psychiatrist, attorney, accountant, financial advisor, investment
consultant or real estate or insurance agent or broker. I understand that these professional occupations are excluded from coverage. I understand that
this insurance will not apply to any partner, principal or owner of a residential/overnight facility. The insurance described herein is subject to the terms,
conditions and exclusions of the insurance certificate. This insurance is excess when other insurance applies to a loss.
In order to enhance the stability of this professional liability insurance program, coverage has been organized through a purchasing group,
pursuant to legislation, known as the Federal Liability Risk Retention Act of 1986, enacted by Congress. Coverage is provided to the purchasing group
by the Chicago Insurance Company, a member of Interstate National Corporation, one of The Fireman’s Fund Insurance Companies. Once the
completed application has been approved and the premium has been received, you will automatically become a member of the Allied Health Purchasing
Group Association, located and domiciled in Illinois and obtain the insurance coverage afforded through the Group Policy on an annual term.
This application is subject to the underwriter’s approval. Your completion of this application and premium payment does not bind coverage
or obligate the insurance company to issue you insurance coverage. Coverage will become effective following the receipt of your acceptable application
and premium payment. Your application cannot be processed unless it is completed in its entirety. The application is subject to the company’s
underwriting rules.
I declare the information contained in the application is true and that no material facts have been suppressed or misstated.
I understand that incorrect information could void the protection. Any person who knowingly and with intent to defraud any insurance company or
other person files an application for insurance containing any false information, or conceals, for the purpose of misleading, information concerning
any fact material thereto, commits a fraudulent insurance act.
Note to New York Applicants: Any person who knowingly and with intent to defraud any insurance company or other person files an application
for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any
fact material thereto, commits a fraudulent insurance act which is a crime, and shall also be subject to a civil penalty not to exceed $5,000 and that
stated value of the claim for each such violation.
Marsh Affinity Group Services may have agreements with insurers providing the insurance coverage which is placed by Marsh pursuant to which Marsh
may derive compensation contingent upon such factors as the size, growth and/or overall profitability of total business placed by Marsh may receive
such as retail and wholesale brokerage fees or commissions, administrative fees, etc.
Coverage is effective the date* your application and payment are received and approved in our offices unless another later date is shown
here__________________________________.
*Effective date may not be earlier than the date Marsh Affinit y Group Services receives and approves this application.
(Do not, however, submit an application more than 90 days prior to the effective date desired.)
I have enclosed my remittance of $_________________________.
Make Check or Money Order Payable to the appropriate administrator below.
Send Student application and payment to:
I authorize Seabury & Smith to charge my:
Visa
MasterCard
$ __________________________________________________
Credit Card Number ____________________________________________ Expiration Date ______________________________________
Print name exactly as it appears on card ____________________________________________________________________________________________
Marsh Affinit y Group Services
a service of Seabury & Smith
75 Remittance Drive, Suite 1788
Chicago, IL 60675-1788
1-800-503-9230
For Ohio residents only
Maginnis & Associates Agency of Ohio
P.O. Box 543
Reynoldsburg, OH 43068-0543
1-800-345-6917 (Ohio residents)
1-614-866-3195 (Columbus area)
YOU MUST SIGN AND DATE THIS APPLICATION
✗
Signature __________________________________________________Date ____________________________