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
Gender:

Other
Race/Ethnicity

Other
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
Current Employment Status:
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%).
Do you have experience working in an immunohematology reference laboratory?
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 agree the following statements
Date

MonthDayYear
Date
Signature
Should be Empty:

SBB Application Form

General Information

Education

Employment & Experience

Associated Forms