Fill - Free fillable Medical Laboratory Assistant Fall 2021 Program Application (Anne Arundel Community College) PDF form

Medical Laboratory Assistant

Fall 2021 Program

Application

Application Deadline: June 15, 2021

ADMISSION REQUIREMENTS

To become a candidate for selection to the Medical Laboratory Assistant (MLA) Program, please complete and return

the attached application by email to vbardhi@aacc.edu

or mail application to:

Anne Arundel Community College

ATTN: School of Health Sciences, FLRS 112

101 College Parkway

Arnold, MD 21012

First consideration will be given to candidates whose resident address is in Anne Arundel County for at least three

months prior to the date the application is submitted. The Address Verification form must be submitted with the

application. Out-of-county applicants will be reviewed if space is available.

Priority will be given to candidates who are currently in or have recently completed the AACC Phlebotomy Technician

Letter of Recognition Program in the past three years prior to the date the application is submitted or who have worked

at least one year as a phlebotomist.

Applicants who have phlebotomy experience but not through AACC’s Phlebotomy Technician Program must make an

appointment with the MLA Program Academic Chair prior to submitting an MLA Program application.

To be considered for conditional acceptance, the applicant must meet the following criteria:

•

Attend an information session prior to submitting application. Please visit https://www.aacc.edu/apply-and-

will be reviewed.

•

Real-time virtual information sessions will be considered face-to-face.

•

High school graduate or equivalency: Official high school transcripts or official GED equivalency certificate to

verify high school graduation or equivalency.

o The application will not be considered complete if required official transcripts are not submitted with the

application or previously submitted to the AACC Records Office.

•

Demonstrate eligibility for ENG 101/ENG 101A.

•

Demonstrate eligibility for general education mathematics or have a score of 27 or better on the Arithmetic

Placement Test or a grade of B or better in Arithmetic (MAT 005).

•

Submission of official transcripts, if applicable. Official transcripts are to be received by AACC Records and

Registration office in the sending institution’s original sealed envelope or through an acceptable electronic

method; visit https://www.aacc.edu/apply-and-register/credit-application/apply/transfer-credit-to-aacc/

for

details.

•

Must be 18 years of age or older by the first day of class.

•

Have a minimum adjusted grade point average (GPA) of 2.0 at this college.

Eligible applicants will receive a selection packet assigning them to one of the following categories:

•

Conditional Acceptance: Applicants who have met the academic and admission requirements and have been

selected into the Medical Laboratory Assistant Program. With the selection packet, conditionally accepted students

will receive the health examination record, criminal background check and CPR instructions to be completed by a

designated deadline. Conditional acceptance candidates who do not meet this deadline will not be considered for

admission and the next person on the list will be contacted.

•

Wait List: In the event there are more qualified applicants than seats available, qualified applicants not initially

conditionally accepted will be placed on a list in rank order and notified of selection if and when seats become

available. If applicant declines the seat, they will need to reapply for a future seat in the program.

Final acceptance into the program will be contingent upon satisfactory completion of a criminal background check,

health examination record and submission of a copy of the required CPR card.

IMPORTANT INFORMATION

Direct all inquiries regarding the application process to Valerie Bardhi via email at vbardhi@aacc.edu.

Following review of all applications, students will receive an email regarding the status of their application. Any

applicant having a change of mailing address, email address, or telephone number during the application

process must notify the Admissions Office by email at

vbardhi@aacc.edu.

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

a complete criminal background check. All student applicants’ final acceptance in the program shall be

contingent upon satisfactory completion of a criminal background check.*

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 are 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 in any and all

programs to comply with drug screening.

AACC will only accept criminal background checks performed by college approved vendor. Criminal background

checks are completed online and must be paid for by the student. Information and instructions are given to

applicants once accepted into the program.

MEDICAL LABORATORY ASSISTANT

Fall 2021

Application Deadline – June 15, 2021

Program Application

Submit completed application to vbardhi@aacc.edu or via mail to Anne Arundel Community College, ATTN: School of

Health Sciences, FLRS 112, 101 College Parkway, Arnold, MD 21012.

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

as well as the Records Office of name, address and phone number changes during the application process. Applicants are

advised to check their AACC email account periodically for placement updates and notices.

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:

I have an active admission status at AACC and am in Good Standing (2.0 GPA>) with the college.

All admission requirements, including testing and eligibility, must be completed by the application deadline.

I have submitted an official copy of my high school transcripts or GED equivalency certificate to the AACC

Records Office or have confirmed that it is on file with AACC Records office.

I must submit final official transcripts from previously attended colleges from which I am transferring courses

toward the Medical Laboratory Assistant Program by the stipulated deadline. International students must submit

official transcript evaluation report from ECE, WES or SpanTran to verify/authenticate high school/college

transcripts by the stipulated deadline.

I am or will be at least 18 years of age or older by the first day of class.

I have attended a mandatory Medical Laboratory Assistant Program information session.

I have submitted a phlebotomy experience form, signed by my employer, if applicable.

If information is incomplete/missing from my application or file, it will NOT be processed and will be returned to

me.

I understand that by filling in my name below, it will be considered my signature.

SIGNATURE: DATE:

ADMISSION/ACADEMIC REQUIREMENTS

Please answer the following questions:

High School Graduate or Equivalency

Yes No I have submitted an official high school transcript or official GED equivalency certificate and have

confirmed that it is on file with the AACC Records office.

Math and English Eligibility

Yes No I have demonstrated English eligibility and am eligible for ENG 101/ENG 101A.

Yes No I have demonstrated eligibility for general education mathematics or a score of 27 or better on the

Arithmetic Placement Test or a B or better in Arithmetic (MAT 005).

Information Session

Yes No I have attended an MLA information session. Date:

INTERNATIONAL STUDENTS

Have you submitted an official transcript evaluation report from ECE, WES or SpanTran to verify/authenticate your high

school and/or college transcripts to the Records Office?

Yes No Agency Used:

PHLEBOTOMY EXPERIENCE (IF APPLICABLE)

Yes No I have successfully completed the Phlebotomy Technician Letter of Recognition at Anne Arundel

Community College with a GPA of 2.0 or higher. Students must complete all required courses with a

grade of C or better.

Completion Date:

Yes

I am currently enrolled in the Phlebotomy Technician Letter of Recognition Program at Anne

Arundel Community College.

Yes

I have phlebotomy experience but not through Anne Arundel Community College.*

I am decelerating from the MLT Program at Anne Arundel Community College into the MLA

Program.

*Applicants who have phlebotomy experience must complete page 8 of this application and have their employer verify

their experience. Contact vbardhi@aacc.edu

for assistance.

Note: Applicants who have phlebotomy experience but not through Anne Arundel Community College’s Phlebotomy

Technician Program must make an appointment with the Medical Laboratory Assistant Program Academic Chair prior to

submitting a Medical Laboratory Assistant Program application.

BACKGROUND INFORMATION

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

to tdneall@aacc.edu

or mailed separately to address on first page of this application, ATTN: Tammie Neall.

Do not write explanation(s) on the application

Yes

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

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

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

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

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

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 Assistant, 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 Assistant Program shall be contingent upon satisfactory completion of a criminal background check and

satisfactory completion of a health examination record.

I understand that by filling in my name below, it will be considered my signature.

Signature: Date:

PRINT NAME:

Notice of Nondi

scrimination: 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.

Please review prior to submitting this application. This application must be completed in its entirety.

Note: This is for informational purposes only and does not affect the admission process.

Name: Date:

WRITTEN STATEMENT

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

plan to pursue the Medical Laboratory Assistant profession.

ANNE ARUNDEL COMMUNITY COLLEGE MEDICAL LABORATORY ASSISTANT PROGRAM

101 College Parkway, Arnold, MD 21012 Application Fall 2021 Program

PHLEBOTOMY EXPERIENCE VERIFICATION FORM

It is not required to have phlebotomy experience; however, preference is given to candidates who are currently in or have

completed the Anne Arundel Community College Phlebotomy Technician Letter of Recognition Program in the past three years

prior to the date the application is submitted or who have worked at least one year as a phlebotomist. To verify phlebotomy

experience, the employer must complete this verification form.

APPLICANT INFORMATION

Name:

Address:

Telephone Number:

Employer:

Address:

Telephone Number:

Name of Business:

Position Held:

Description of Duties:

Supervisor:

Telephone Number:

Dates of Employment/Experience:

From: To:

Number of Months Worked:

Full-time Part-time

Total Hours of Phlebotomy Experience From This Employer:

STATEMENT OF CERTIFICATION

I certify that all the information I have provided on this form is true, complete and correct to the best of my knowledge and belief, and is

made in good faith. I know and understand that any or all items contained herein are subject to verification and I consent to the full release

of information from the employer listed for the purpose of verifying the information I have provided. I understand that by filling in my name

below, it will be considered my signature.

Applicant Signature Date

EMPLOYER VERIFICATION

Please complete this form and return it in a sealed and signed envelope to the applicant.

Or submit to vbardhi@aacc.edu.

Signature of Supervisor

Title

Date

Printed Name

Name of Company & Department

Telephone Number

COMMENTS:

This page is left intentionally blank.

ADDRESS VERIFICATION

The Address Verification Form is part of the application packet and must be completed in its entirety with two supporting

documents.

Applications received without this form and documentation will be considered incomplete and will be returned

to the applicant.

Be certain to include two (2) forms of supporting documentation as stipulated on the form.

Consideration will be given only to candidates whose verified resident address is in Anne Arundel County for at least three

months prior to the date the application is submitted.

Questions pertaining to this form can be addressed to Melissa Mumma in the Records Office at 410-777-2721 or

mamumma@aacc.edu.

Out-of-county/state applicants will be reviewed only when space is available.

December 2020

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.

OFFICE USE ONLY

Program: MLA

Verify Term: SP21

101 College Parkway, Arnold, Maryland 21012-1895 410-777-2243

ADDRESS VERIFICATION FOR HEALTH SCIENCE PROGRAM APPLICANTS

Directions: This form must be completed entirely and supporting documents submitted as part of the health sciences

program application process. Applications submitted without this document will be returned as incomplete.

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.

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.

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 addresses 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 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.

Example: All documents must be dated three months prior to application submission date.

Acceptable Documents

 Maryland Driver’s License

 Voter Registration Card

 Copy of Deed of Trust or Signed Lease

 Maryland Withholding Form – MW 507 (Not U.S. W-2)

 Maryland Income Tax Return (not U.S.)

 Utility Bill including gas, electric, water, phone, cable, etc.

 Vehicle Registration Card

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

SECTION A – TO BE COMPLETED BY STUDENT

Student Name

Student ID or SSN (last 4 digits)

Resident Address

City

State

Zip

County

Day Phone

Evening

Dates of Occupancy at above address

 Own

 Rent

Previous Address

City

State

Zip

How long did you live at this previous address?

Are you registered to vote?  Yes  No

County

State

Do you possess a valid driver’s license?  Yes  No

If yes, what state issued?

County

Date of Issuance

Do you own a motor vehicle?  Yes  No

If yes, in what state issued?

County

Date of Issuance

Do you have the use of another person’s motor vehicle?  Yes  No

If yes, provide name

Relationship to student

Are you paying Maryland income tax for this year on all earned income?  Yes

 No

If yes, what county?

List where you have filed tax returns for the past two (2) years:

Year State County

If employed, is Maryland income tax currently being withheld?  Yes  No

If yes, what county?

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 the above question is “Yes”, SECTION B of this form must be completed by your supporter.

Additional Information

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

____ MD driver’s license ____ Military ID (& Dependent ID if spouse or dependent)

____ MD income tax return (not U.S.) ____ Copy of Orders

____ Voter Registration Card ____ Copy of housing assignment, lease, deed or utility bill

____ Vehicle registration showing resident address

____ Utility bill showing home address

____ Copy of deed of trust or signed lease

____ 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 YOU ANSWERED “YES” to the following question:

For the most recent 12 months, has another person(s) provided one-half or more of your financial support?

Name of supporter

Relationship to student

Supporters Address

City

State

Zip

County

Day Phone

Evening

Date of Occupancy at above address

 Own

 Rent

Previous Address

City

State

Zip

How long did you live at this previous address?

Are you registered to vote?  Yes

 No

County

Do you possess a valid driver’s license?  Yes

 No

If yes, in what state issued?

County

Date of Issuance

Do you own a motor vehicle?  Yes

 No

If yes, in what state issued?

County

Date of Issuance

Do you have the use of another person’s motor vehicle?  Yes  No

If yes, provide name

Relationship to student

Are you paying Maryland Income tax for this year on all earned income?  Yes  No

If yes, which county?

List where you have filed tax returns for the past two (2) years:

Year State County

If employed, is Maryland income tax currently being withheld? Yes

 No

If yes, in which county?

Additional information:

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

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.

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