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 Bill Martinez at gamartinez@lifesouth.org. Good luck!

General Information

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

MT/MLS Certification Number *

Granted by *

U.S. Citizen? *

Yes

Residence Card or Student Visa? *

Yes

N/A

Education

Please provide a complete record of your undergraduate education, including MT/MLS training, as applicable. Any entry including the institution’s name requires all fields to be completed. Submit copies of all transcripts or transcript evaluations for with initial review packet.

College or University *

From * +

To * +

City *

State *

Country *

Degree *

Major

Minor

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College or University

From +

To +

City

State

Country

Degree

Major

Minor

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College or University

From +

To +

City

State

Country

Degree

Major

Minor

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College or University

From +

To +

City

State

Country

Degree

Major

Minor

Work Experience

Please provide information on applicable work experience following completion of a baccalaureate degree

Name of Employer *

From * +

To * +

Street Address *

City *

State *

Supervisor *

Reason for leaving *

Job title and essential duties, tests, and tasks performed in this position *

Percentage of time spent working in the Blood Bank *

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Name of Employer

From +

To +

Street Address

City

State

Supervisor

Reason for leaving

Job title and essential duties, tests, and tasks performed in this position

Percentage of time spent working in the Blood Bank

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Name of Employer

From +

To +

Street Address

City

State

Supervisor

Reason for leaving

Job title and essential duties, tests, and tasks performed in this position

Percentage of time spent working in the Blood Bank

For additional related experience, please submit a separate attachment

Professional References

Please submit two (2) letters of recommendation from people who are familiar with you on a professional level and your experience. Letters must be signed by the author and letterhead is preferred. Letters should be uploaded in the available space below.

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

Occupation *

Letter of Recommendation 1

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

Occupation *

Letter of Recommendation 2

Curriculum Vitae

Please submit your CV here *

Undergraduate Transcript

Please upload a copy of your undergraduate transcript here: *

Personal Statement

Please submit a personal statement (1-2 pages) that addresses the following topics:

- What are your career goals?

- Describe your professional strengths.

- What experiences or qualities do you have that will help you succeed in a distance-learning program?

- Describe how you see this program affecting your life.

- List any honors, awards, and activities that may be applicable, such as organization memberships, publications, and presenatations at seminars or meetings.

Submit your personal statement here *

SBB Applicant Experience Documentation

Please submit your SBB Applicant Experience Documentation form here *

Agreement for SBB Student Mentoring

Please submit your signed Agreement for SBB Mentoring form and your mentor's CV here *

Facility Information

Please submit your Facility Information Form here *

Facility Memo of Understanding

Please upload your signed Facility Memo of Understanding form here *