Medical Laboratory Technician Program Application

Applications Available: December, 2017

Application Deadline: April 15, 2018 Program Start: Fall, 2018

ADMISSION REQUIREMENTS

• Attend an Information Session. Please visit http://www.aacc.edu/apply-and-register/credit-application/health-science-applicants for dates and times. Information Sessions can also be viewed online.

• Students must demonstrate eligibility for ENG 111, ENG 115, or ENG 121 as evidenced by one of the following: o Satisfactory ACT (18 or better) or SAT (510 or better) scores according to the college standard.

If available, please submit a copy of the scores to the Records office OR o Satisfactory scores on the English Placement Test** OR o Successful completion of noncredit developmental English and reading requirements as

determined by ACT or SAT or English Placement Test scores** OR o Transfer of credits for ENG 111 from other institutions or credits awarded on basis of CLEP or

advanced placement exam.

• Students must demonstrate eligibility for MAT 137 College Algebra by one of the following: o Satisfactory ACT or SAT scores according to the college standard. If available, please submit a

copy of the scores to the Records office OR o Satisfactory scores on the Mathematics Placement Test** OR o Successful completion of noncredit developmental math courses based on the mathematics

placement test scores OR o Transfer of credit for MAT 012, MAT 037, or MAT 045 from an institution of higher learning OR o Transfer of credits for MAT 137 course from an institution of higher learning o Students who previously took MAT 121, 131, 141, 142, 151, or 191 can use that course to

satisfy the MAT 137 requirements

• Have a minimum adjusted GPA of 2.0 at AACC. • Submitted a photocopy of your Maryland driver’s license or government-issued I.D. card or AACC

student I.D. card.

IMPORTANT INFORMATION

• Direct all inquiries regarding the application process to Karen Frank via email at klfrank1@aacc.edu. • Letters will be sent to students at the address listed on this application the month of June, 2018.

Any applicant having a change of mailing address, e-mail address, or telephone number during the application process must notify the admissions office by email at klfrank1@aacc.edu.

• All health sciences students who are offered admission and/or clinical placement will be required to

submit a complete criminal background check and urine drug screen. All student applicants’ final acceptance in the program shall be contingent upon satisfactory completion of a criminal background check and of a urine drug screen.* All letters of acceptance shall state that the acceptance is conditional and contingent on submission to a criminal background check and urine drug screen—as may be required by the program--that results in satisfactory reports. If an accepted student tests positive for an illegal or un-prescribed drug, the student shall be denied admission or terminated from any health sciences program.

Separate, additional criminal background checks and urine drug screens may be required by clinical sites prior to placements. Students with an unsuccessful background check or urine screening who is denied by a clinical site that is required to meet program competencies shall be dismissed from the program and their registrations shall be withdrawn from courses related to the program of study. If the student tests positive for an illegal or un-prescribed drug, the student shall be denied admission or terminated from any health sciences program even if a denied placement was not required to meet program competencies. Successful reports of criminal background checks and urine drug screens do not assure eligibility for specific clinical site placement, program completion, and/or eligibility to sit for professional licensure/board examinations. Students are reminded that licensing boards for certain health care occupations and professions may deny, suspend, or revoke a license or may deny the individual the opportunity to sit for an examination even if the individual has completed all program course work if it is determined that an applicant has a criminal history or has been convicted of, or pleads guilty, or pleads nolo contendere or the like to a felony or other serious crime. Successful completion of a health sciences program of study at Anne Arundel Community College does not guarantee licensure, the opportunity to sit for a licensure examination, certification or employment in the relevant health care occupation. Students may be automatically denied admission or, if enrolled, dismissed from the program if they have not been truthful or have provided inaccurate information on the application or on any other form or submission. Students who have questions or concerns are encouraged to contact the Health Sciences Admissions Office at healthsciencesadmissions@aacc.edu. * Notwithstanding the statements herein regarding urine drug screens, as of September 2010, only certain programs will be requiring drug screening. AACC shall inform students which programs presently require them. However, AACC, at any time, has the right, upon notice, to require any and all students and any and all programs to comply with drug screening.

MEDICAL LABORATORY TECHNICIAN PROGRAM

FALL 2018 Application Deadline – April 15, 2018

Program Application

DEMOGRAPHIC INFORMATION (Please print) Last Name First Name Middle

Address City State Zip Code County of Residence

Last 4 digits of social security # College ID #:

The mailing address you provide will be your address of record. It is your responsibility to notify the Health Sciences Office of name, address and phone number changes during the application process. Home Phone Cell Phone Work Phone

AACC Email Address – Required No other email is acceptable @mymail.aacc.edu

Admission/Academic Requirement Checklist By signing below, I agree/understand the following:

1. I have an active admission status at AACC and am in Good Standing (2.0 GPA>) with the college. 2. All admission requirements, including prerequisites, must be completed by the application deadline. 3. I must submit final official transcripts from previously attended colleges from which I am transferring courses

toward the Medical Laboratory Technician program by the stipulated deadline. International students must submit official transcript evaluation report from ECE or WES to verify/authenticate college transcripts by the stipulated deadline.

4. Photo copy of driver’s license or other government-issued photo I.D., or AACC photo I.D. is attached.

SIGNATURE: DATE:

ADMISSION/ACADEMIC REQUIREMENTS Please answer the following questions:

Math and English Eligibility Yes No I have demonstrated English eligibility and am eligible for ENG 111, ENG 115 or ENG 121 Yes No I have demonstrated eligibility for MAT 137 College Algebra.

Information Session Yes No I have attended a MLT Information Session. Date: Information Sessions can also be viewed online. Please visit: www.aacc.edu/apply-and-register/credit-application/health-science-applicants

INTERNATIONAL STUDENTS Have you submitted an official transcript evaluation report from ECE or WES to verify/authenticate your high school and/ or college transcripts to the records office?

Yes No Agency Used:

GENERAL EDUCATION COURSES Please complete the following information (if applicable).

COURSE GRADE CREDITS COLLEGE WHERE COMPLETED

TERM AND YEAR

COMPLETED

Human Biology 1 BIO 231

OR

†A & P 1 BIO 233

General Microbiology BIO 223

General Chemistry CHE 111

Comp & Intro to Literature 1 ENG 111

OR Comp & Intro to Literature 1 for Non-Native Speakers ENG 115

OR

Comp and Literature ENG 121

Computing and Information Technology (formally CSI 112) CTA 100

OR Theories and Applications of Digital Technology (formally CSI 113 & CTA 103) CTP 103

*College Algebra MAT 137

Introduction to Sociology SOC 111

Fund. of Oral Communication COM 111 OR Fund. of Oral Communication For Non-Native Speakers COM 116

† This course has a prerequisite of BIO 101. *MAT 121,131,141,142,151or 191 can be used to satisfy this requirement.

BACKGROUND INFORMATION

Submit explanation of questions for which you answer "yes" and provide documents relating to your answer in

a sealed envelope attached to this application. Attention: Tammie Neall

Do not write explanation(s) on the application.

Yes �

No �

Were you ever disciplined for any academic or behavior/conduct issue by any college, university, or any other educational institution after High School including, but not limited to, probation, dismissal, suspension, disqualification, or imposition of a failing grade as a disciplinary sanction? If your answer is yes provide a written explanation and all relevant documents relating thereto.

Yes �

No �

Have you ever been convicted of a crime, driving while intoxicated or impaired (either by alcohol or drugs), had your driving privileges suspended or revoked, and/or are there any pending charges regarding any of the above? If your answer is yes provide a written explanation and all relevant documents relating thereto.

Yes �

No �

Have you ever surrendered your driver's license or had such license suspended or revoked? If your answer is yes provide a written explanation and all relevant documents relating thereto.

Yes �

No �

Have you ever surrendered a professional license, certification or registration, or had one restricted, suspended or revoked? If your answer is yes provide a written explanation and all relevant documents relating thereto.

Yes � No �

Have you ever been placed on professional probation, had conditions or limitations placed on your ability to work even if your license had not been restricted, suspended or revoked? If your answer is yes provide a written explanation and all relevant documents relating thereto.

Yes �

No �

Have you ever had your clinical privileges at any office or facility restricted, suspended or revoked? If your answer is yes provide a written explanation and all relevant documents relating thereto.

NOTE: Licensing boards for certain health care occupations, including Medical Laboratory Technician, may deny, suspend, or revoke a license or may deny the individual the opportunity to sit for an examination even if the individual has completed all program course work, if it is determined that an applicant has a criminal history or is convicted or pleads guilty or nolo contendere to a felony or other serious crime. If applicable, it is recommended to contact national certifying boards for your program of interest.

I certify that the information on this application is true and accurate to the best of my knowledge. I am aware that falsification or misrepresentation may result in being denied admission, or if enrolled, dismissed from this program. I understand that final acceptance into the Medical Laboratory Technician program shall be contingent upon satisfactory completion of a criminal background check and satisfactory completion of a health examination record.

Signature: Date:

PRINT NAME: Notice of Nondiscrimination: AACC is an equal opportunity, affirmative action, Title IX, ADA Title 504 compliant institution. Call Disability Support Services, 410-777-2306 or Maryland Relay 711, 72 hours in advance to request most accommodations. Requests for sign language interpreters, alternative format books or assistive technology require 30 days’ notice. For information on AACC’s compliance and complaints concerning sexual assault, sexual misconduct, discrimination or harassment, contact federal compliance officer at 410-777-1239 or complianceofficer@aacc.edu or Title IX coordinator at 410-777-2256, or Maryland Relay 711.

WRITTEN STATEMENT Submit a written statement consisting of a minimum of two paragraphs explaining why you

plan to pursue the Medical Laboratory Technician Profession. Note: This is for informational purposes only and does not affect the admission process. Name: Date:

Anne Arundel Community College MLT Program 101 College Parkway Arnold, Maryland 21012-1895 / Records and Registration Office / SSVC 140 VERIFY: Fall 2018 410-777-2243 / Fax 410-777-2489 / records@aacc.edu / www.aacc.edu/recreg / MyAACC http://myaacc.aacc.edu

Directions: This form must be completed entirely and documents submitted as part of the health sciences program application process.

If you the student support yourself, provide a minimum of two of the documents listed below in your name, at current resident address that are dated three months prior to the application deadline date.

OR If for the most recent 12 months, you, the student, have resided in Anne Arundel county, but are supported by someone in another Maryland county or state, provide a minimum of two of the documents listed below in your name, at current resident address that are dated three months prior to the application deadline date.

OR If for the most recent 12 months, another person(s) has provided one-half or more of your financial support, provide a minimum of two documents listed below in your supporter’s name, showing current resident address that are dated three months prior to the application deadline date. In addition, you will need to provide one document from the list below in your name showing your current resident address and dated three months prior to the application deadline date in addition to the two documents from your supporter. The supporter must also complete the information requested in Section B. Military Personnel Only: Complete this form with a copy of your military ID (also dependent ID, if spouse or dependent), copy of orders, and a copy of housing assignment, lease, deed or utility bill showing your resident address. Application Term: FALL 2018 Application Deadline: April 15, 2018 Example: If the application deadline date is April 15, 2018, documents must be dated on or before January 15, 2018. Acceptable Documents:

□ Maryland Driver’s License □ Maryland Income Tax Return (not U.S.) □ Voter Registration Card □ Utility Bill: gas, electric, water, phone, cable, etc. □ Copy of Deed of Trust or Signed Lease □ Vehicle Registration Card □ Maryland Withholding Form – MW 507 (not U.S. W-2)

The college reserves the right to request additional information and documentation as necessary.

SECTION A – TO BE COMPLETED BY STUDENT

1. Student Name___________________________________________ Student ID or SSN (Last 4 digits)______________

2. Resident Address___________________________________________________________________ City, State, Zip_____________________________________________________________________ County__________________________ Day Phone: _______________________ Evening: ________________________ 3. Dates of occupancy at above address ____________________________________ ________ ________ Own Rent Previous Address __________________________________________________________________ City, State, Zip ____________________________________________________________________ How long did you live at this previous address? _____________________________

ADDRESS VERIFICATION FOR HEALTH SCIENCES APPLICANTS

5. Are you registered to vote? _____ _____ County and State ___________________________________________ Yes No 6. Do you possess a valid driver’s license? _____ _____ Yes No If yes, in what state issued?__________________ County__________________________ Date of Issuance______________ 7. Do you own a motor vehicle? ______ _____ Yes No If yes, in what state issued?__________________ County__________________________ Date of Issuance______________ 8. Do you have the use of another person’s motor vehicle? ______ _____ Yes No If yes, provide name ____________________________________ Relationship to student____________________________ 9. Are you paying Maryland income tax for this year on all earned income? _____ _____ Yes No If yes, which county? ________________________________________ 10. List where you have filed income tax returns for the past two (2) years. State________________ County__________________________________________ State________________ County__________________________________________ 11. If employed, is Maryland income tax currently being withheld? _____ _____ Yes No If yes, which county? ____________________ 12. For the most recent 12 months, has another person(s) provided one-half or more of your financial support? _____ _____ Yes* No * If the answer to question 12 is “Yes”, SECTION B (next page) must be completed by your supporter. Additional information: ___________________________________________________________________________________ The college reserves the right to request additional information and documentation if necessary. I CERTIFY THAT THE INFORMATION CONTAINED HEREIN IS CORRECT TO THE BEST OF MY KNOWLEDGE. ________________________________________________________ __________________________ Signature of Student (required) Date

OFFICE USE ONLY ACCEPTABLE DOCUMENTS: □ MILITARY / BRAC WAIVER: 1. _____ MD driver’s license 1. _____ Military ID (& Dependent ID, if spouse or dependent) 2. _____ MD income tax return (not U.S.) 2. _____ Copy of orders 3. _____ Voter registration card 3. _____ Copy of housing assignment, lease, deed, or 4. _____ Vehicle registration utility bill showing resident address 5. _____ Utility bill showing home address 6. _____ Copy of deed of trust or signed lease 7. _____ MD withholding form – MW 507 (not U.S. W-2) STATUS OF RESIDENT ADDRESS Anne Arundel county Other MD county Out-of-State Term & Year _________________ _________________________________ __________________________

Authorized Signature Date SECTION B – TO BE COMPLETED BY SUPPORTER IF ANSWER TO QUESTION 12 IN STUDENT SECTION IS “YES” 1. Name of Supporter_______________________________________ Relationship to Student________________________ 2. Supporter’s Address______________________________________ City, State, Zip_________________________________ County____________________________ Day Phone: ________________________ Evening: _______________________ 3. Dates of occupancy at above address _________________________________ ________ ________ Own Rent 4. Previous Address_________________________________________ City, State, Zip _________________________________ How long did you live at this previous address? ____________________________

5. Are you registered to vote? _____ _____ County_________________________________ Yes No 6. Do you possess a valid driver’s license? _____ _____ Yes No If yes, in what state issued?__________________ County_______________________ Date of Issuance_________________ 7. Do you own a motor vehicle? _____ _____ Yes No If yes, in what state issued?__________________ County_______________________ Date of issuance_________________ 8. Do you have the use of another person’s motor vehicle? _____ _____ Yes No If yes, provide name ___________________________________ Relationship to student_____________________________ 9. Are you paying Maryland income tax for this year on all earned income? _____ _____ Yes No If yes, which county? ___________________________________ 10. List where you have filed income tax returns for the past two (2) years. 2015 State________________ County____________________________ 2014 State________________ County____________________________ 11. If employed, is Maryland income tax currently being withheld? _____ _____ Yes No If yes, which county? _________________________________ Additional Information: ___________________________________________________________________________________ The college reserves the right to request additional information and documentation if necessary. I CERTIFY THAT I HAVE SUPPORTED THE ABOVE-NAMED STUDENT FOR THE MOST RECENT 12 MONTHS AND THAT THE INFORMATION CONTAINED HEREIN IS CORRECT TO THE BEST OF MY KNOWLEDGE. _________________________________________________ ______________________ Signature of Supporter Date Notice of Nondiscrimination: AACC is an equal opportunity, affirmative action, Title IX, ADA Title 504 compliant institution. Call Disability Support Services, 410-777-2306 or Maryland Relay 711, 72 hours in advance to request most accommodations. Requests for sign language interpreters, alternative format books or assistive technology require 30 days’ notice. For information on AACC’s compliance and complaints concerning sexual assault, sexual misconduct, discrimination or harassment, contact the federal compliance officer and Title IX coordinator at 410-777-1239, complianceofficer@aacc.edu or Maryland Relay 711.