Application - Virginia Western Community College

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2017 MEDICAL LABORATORY TECHNOLOGY APPLICATION FORM
Virginia Western Community College
Name:
Last
First
.
.
M
I
Social Security Number:
Student I.D.
Mailing Address:
(Street or P.O. Box)
(City)
(State)
(Zip Code)
Telephone: Home (
)
Cell (
)
E-mail Address (if any):
Applicants must meet the general admission requirements for the college. Applicants must have completed the
following prerequisites with a grade of “C” or better by the end of spring 2017: Algebra I – II (or MTE 1 – 9), one
unit of high school or college biology, college Bio 141 Human Anatomy & Physiology I, Chm 111 College
Chemistry I, Eng 111 College Composition I. (BIO 141 must be completed within 5 years prior to entering the
program.) Also, cumulative GPA must be > 2.0 by the end of the fall 2016 semester to be eligible for 2017 program
.
Please answer YES or NO to the following.
Are you a high school graduate? (Year ________ )
Note: An official high school transcript must also be submitted in an original sealed envelope.
If NO, have you completed a GED? _______ (Year _______)
Note: You must submit a copy of GED scores.
Have you been employed or are you currently employed as a Medical Laboratory Assistant (includes specimen
processor) or as a Phlebotomist? If yes, give title.
Have you been enrolled in an MLT program before? If so, where?
Please list all the colleges you have ever attended below
Official transcripts from all colleges attended
.
(including VWCC)
are required to complete application. (No transcripts are needed for VWCC or other community colleges in Virginia.)
Name of College(s)
Date(s) Attended
All applicants must have a complete academic file by May 1, 2017 to be considered. No exceptions. Your academic file consists
official
of your VWCC college application, official sealed transcript from high school, copy of GED scores (if applicable), and
sealed transcripts from colleges and institutions attended/attending.
Application materials should be submitted directly to
the School of Health Professions - Pam Woody. Requesting transcripts is the responsibility of the applicant.
Applicant Signature
Date
Application materials (program application, transcripts, etc.) should be submitted or addressed to Pam Woody,
VWCC-Health Professions, 3091 Colonial Ave., Roanoke, VA 24015 or bring to the Fralin Center for Science and Health
Professions – Room 339 (3
rd
floor). When your academic file is complete, Pam Woody will review and send an advising form
letter to the applicant usually within 3-4 weeks.
It is the policy of the Virginia Community College System and Virginia Western Community College to maintain and promote equal
employment and educational opportunities without regard to race, color, sex, age, religion, disability, national origin, or other non-
merit factors. For further information, contact the Title IX Coordinator, Lori Baker in Chapman Hall, Room C102, phone (540) 857-6348,
TitleIXCoordinator@virginiawestern.edu
or the ADA/Section 504 Coordinator, at the Office of Disability Services, Student Life Building
Room 207, phone (540) 857-7286. TTY number is (800) 855-2880 all users 711

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