SBB Application Form

SBB Application Form

Congratulations on taking the first step to advancing your career in immunohematology! Please fill out this form completely and accurately. If you have any questions, please contact education@lifesouth.org. Good luck!
General Information

Contact & Demographics
Name:*

First NameMiddle NameLast Name
Credentials:*
Examples: BB(ASCP), MT(ASCP), MLS(ASCP), AAB, AMT
Date of Birth:*

MonthDayYear
Date
Email:*
example@example.com
Phone Number:*
Please enter a valid phone number.Format: (000) 000-0000.
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
MaleFemaleNon-BinaryPrefer Not to AnswerOther
American Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoPacific Islander or Native HawaiianMiddle Eastern or North AfricanWhitePrefer Not to AnswerOther
U.S. Citizen?*
Note - We do not currently accept international students.
Education

Please attach Unofficial transcripts below
Highest Degree Awarded:*
Field of Study:*
e.g., Medical Laboratory Science, Biology, Chemistry
Institution Name:*
e.g., University of Florida
Undergraduate Cumulative GPA: *
Enter as a number on a 4.0 scale (e.g., 3.4)
Upload College Transcripts:*

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Employment & Experience

Professional Background
Employed in Blood Bank or Transfusion ServiceEmployed in Medical FieldEmployed in Non-Medical FieldUnemployed
How many years of experience do you have working in a blood bank?*
(Enter a number, decimals allowed, e.g., 2.5)
Approximately what percentage of your work time is spent in the blood bank?*
Enter a whole number (e.g., 75 for 75%).
YesNo
Upload Resume/CV: *

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Associated Forms
Upload SBB Applicant Experience Documentation Form*

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Download Experience Documentation Form:
Upload Facility Information Form*

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Download Facility Information Form:
Upload Agreement for SBB Mentoring and Mentor's CV*

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Download Agreement for SBB Mentoring
Upload Personal Statement (1-2 pages) including discussion of: Career goals, Professional strengths, Experiences or qualities that will help the applicant succeed in a distance learning program, How this program will affect your professional life, List of any honors, awards, and activities that may be applicable (such as organization memberships, publications, and presentations at seminars or meetings*

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Upload Rotation Planning Form*

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Download Rotation Planning Form
Please provide any additional information you think might be helpful or relevant
I confirm that all of the information I provided here are true and accurate.I understand that any false or omitted information provided here may result in termination of right of SBB program.I hereby grant permission for LifeSouth Community Blood Centers to receive all information regarding my employment and/or scholastic standing with your organization/institution.
Date*

MonthDayYear
Date
Signature*

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SBB Application Form

General Information

Education

Employment & Experience

Associated Forms