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APPLICATION SELECTION TO PHLEBOTOMY PROGRAM HINDS COMMUNITY COLLEGE 1750 CHADWICK DRIVE JACKSON MISSISSIPPI 39204-3490 601 376-4805 Social Security No. Home Telephone No. Cell Phone No. E-mail address INSTRUCTIONS A. B. Phlebotomy Program Office of Admissions Nursing/Allied Health Center 1750 Chadwick Drive Jackson MS 39204-3490 Complete this form PLEASE TYPE OR PRINT and return to Request the registrar of each high school or college you have attended to forward an original transcript from that institution to PERSONAL DATA Name First Middle Maiden Last Address Street No* / PO Box / Route City State Zip EDUCATIONAL DATA List all colleges and professional schools attended* Name of School City and State Did you graduate Dates attended Yes No mo/year Check ONLY one box please Phlebotomy Phlebotomy Fast Track for people with direct health care experience only INDIVIDUAL STUDENT DATA The following information is needed for counseling regarding licensure/registry requirements. Do you have a history of alcohol or drug abuse If yes have you ever been rehabilitated Have you ever been convicted of a misdemeanor or felony If yes Explain Individuals who have been convicted pleaded guilty or pleaded no contest to certain felony crimes may be unable to attend clinical training or obtain employment in a licensed health care facility in Mississippi. Applicants convicted of a misdemeanor or felony offense may be denied licensure/certification* I certify that the statements in this application are true and complete to the best of my knowledge and that I have attended no institution other than those listed therein* I am aware that falsification of information is a basis for denying admission or for immediate termination of enrollment. B. Phlebotomy Program Office of Admissions Nursing/Allied Health Center 1750 Chadwick Drive Jackson MS 39204-3490 Complete this form PLEASE TYPE OR PRINT and return to Request the registrar of each high school or college you have attended to forward an original transcript from that institution to PERSONAL DATA Name First Middle Maiden Last Address Street No* / PO Box / Route City State Zip EDUCATIONAL DATA List all colleges and professional schools attended* Name of School City and State Did you graduate Dates attended Yes No mo/year Check ONLY one box please Phlebotomy Phlebotomy Fast Track for people with direct health care experience only INDIVIDUAL STUDENT DATA The following information is needed for counseling regarding licensure/registry requirements. Do you have a history of alcohol or drug abuse If yes have you ever been rehabilitated Have you ever been convicted of a misdemeanor or felony If yes Explain Individuals who have been convicted pleaded guilty or pleaded no contest to certain felony crimes may be unable to attend clinical training or obtain employment in a licensed health care facility in Mississippi. Do you have a history of alcohol or drug abuse If yes have you ever been rehabilitated Have you ever been convicted of a misdemeanor or felony If yes Explain Individuals who have been convicted pleaded guilty or pleaded no contest to certain felony crimes may be unable to attend clinical training or obtain employment in a licensed health care facility in Mississippi. Applicants convicted of a misdemeanor or felony offense may be denied licensure/certification* I certify that the statements in this application are true and complete to the best of my knowledge and that I have attended no institution other than those listed therein* I am aware that falsification of information is a basis for denying admission or for immediate termination of enrollment.

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  • REGISTRAR
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