MLT Student Intake Form
This is a 4 part application
Name
*
First Name
Middle Name
Last Name
Date Of Birth
*
-
Month
-
Day
Year
Date
Panola College Student ID #:
Email
*
example@example.com
Cell Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Have you applied to the MLT program before?
*
Yes
No
Semester you are applying for:
*
Fall
Spring
Are you a Registered Phlebotomist?
*
Yes
No
List of Agency:
Back
Next
Part II - Education
List all colleges previously attended
Check each level of education you have completed:
*
High School Diploma
Associate's Degree
GED
Other
How many colleges have you attended prior to Panola College?
*
0
1
2
3
4
#1 College Name:
*
College City and State
*
Dates Attended:
*
#2 College Name:
*
College City and State
*
Dates Attended:
*
# 3 College Name:
*
College City and State
*
Dates Attended:
*
# 4 College Name:
*
College City and State
*
Dates Attended:
*
Upload a copy of your transcript evaluation from the Academic Admissions office and if you are a Certified Phlebotomist then add that as well.
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Back
Next
Part III - Essay
Write a brief paragraph explaining why you would like to become an MLT
*
Write a brief paragraph explaining what you think MLTs do
*
Write a brief paragraph about how being an MLT fits into your future career goals
*
Back
Next
Part IV - Checklist & Certification
I certify that:
I have
applied for admission to Panola College
I have sent official transcripts from my high school or all previously attended colleges and universities to the Panola College admissions office.
Attach a copy of my transcript Evaluation from admissions.
All information provided in this application is true and complete. This application has been initially submitted and signed electronically.
It is my responsibility to provide all requested information to complete my file. Failure to provide all requested information may adversely affect my evaluation.
I understand and agree to actively participate in the learning process as required.
Signature
Submit
Should be Empty: