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Medical Laboratory Technician Program Application (Anne Arundel Community College)

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Medical Laboratory Technician
Program Application
Application Deadline: April 15, 2021
Program Start: Fall 2021
ADMISSION REQUIREMENTS
To become a candidate for selection to the Medical Laboratory Technician 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.
To be considered for conditional acceptance, the applicant must meet the following criteria:
• 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. Admission and selection information will be reviewed. Virtual information sessions will be
considered face-to-face.
• Demonstrate eligibility for ENG 101/ENG 101A.
• Demonstrate eligibility for MAT 137, College Algebra. MAT 145, 151, 191 or 230 satisfies the MAT
137 requirement (former MAT courses 121, 131, 141, or 142 will also satisfy the MAT 137
requirement).
• Submission of official transcripts, if applicable. Official transcripts are to be received by AACC’s
Records and Registration office in the sending institution’s original sealed envelope or through
acceptable electronic method. Visit
https://www.aacc.edu/apply-and-register/credit-
application/apply/transfer-credit-to-aacc/ for details.
• Must have a minimum adjusted grade point average (GPA) of 2.0 at this college.
Following review of applications, students will receive an email sent to their AACC email account regarding
the status of their application.
Eligible applicants will receive a selection packet assigning them to one of the following categories:
o Conditional Acceptance: Applicants who have met the academic and admission
requirements and have been selected into the program are given conditional acceptance.
Students who are granted conditional acceptance must submit a criminal background check,
health examination record and current American Heart Association Basic Life Support (BLS)
CPR certification by designated deadlines. Those who do not meet these deadlines will not be
further considered for admission.
o Wait List: In the event there are more qualified applicants than seats available, qualified
applicants not initially selected for conditional acceptance will be placed on a list in rank order
and notified of selection when a seat becomes available. If applicant declines the seat, they
will need to reapply for a future seat in the program.
o Final acceptance: Applicants who have been selected conditionally and have submitted complete
health examination records, submitted a satisfactory criminal background check, and verification of
a valid American Heart Association BLS CPR certification.
IMPOR
TANT INFORMATION
1. A mandatory, virtual meeting will be held on Friday, April 16, 2021 from 2:00 p.m. to 4:00 p.m. for all
applicants. The purpose of this meeting is to review the selection process and provide information
regarding the required health examination record and other program requirements. All students who
are seeking admission to the fall 2021 class must attend this meeting and remain for the entire
meeting. Students who are unable to attend this meeting must email the Health Sciences Admissions
Coordinator, Valerie Bardhi, at vbardhi@aacc.edu
in advance of the meeting. Failure to attend this
meeting without prior notification will eliminate you from consideration into the fall 2021 MLT Program.
It is your responsibility to check your AACC email account for notifications from the Health Sciences
Admissions Office.
2. Dir
ect 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 letter 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.
3. All health sciences students who are offered admission and/or clinical placement will be required to
submit to 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 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.
MEDICAL LABORATORY TECHNICIAN
FALL 2021
Application Deadline – April 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
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:
1. I have an active admission status at AACC and am in Good Standing (2.0 GPA>) with the college.
2. All academic admission requirements, including prerequisites, must be completed by the application deadline.
Pass/Fail grades are not acceptable.
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, WES, or SpanTran to verify/authenticate college
transcripts by the stipulated deadline.
4. I have submitted the Address Verification Form with this application including two supporting documents.
5. If information is incomplete/missing from my application or file, it will NOT be processed and will be returned to
me.
6. I understand that I must attend the mandatory virtual applicant meeting on April 16, 2021 from 2:00 to 4:00 PM.
7. I understand that by filling in my name below, it will be considered my signature.
SIGNATURE
:
DATE
:
click to sign
signature
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ADMISSION/ACADEMIC REQUIREMENTS
Please answer the following questions:
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 MAT 137 College Algebra.
Information Session
Yes No I have attended an MLT Information Session. Date:
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, WES, or SpanTran 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).
Must be completed with a grade of C or better.
Due to the selection process, the Medical Laboratory Technician Program cannot accept Pass/Fail as a
replacement for letter grades in the required courses.
COURSE
GRADE CREDITS
COLLEGE WHERE
COMPLETED
TERM AND
YEAR
COMPLETED
BIO 231 Human Biology 1
OR
†BIO 233 Anatomy and Physiology 1
BIO 223 General Microbiology
CHE 111 General Chemistry
ENG 101/ENG 101A Academic Writing
and Research 1
ENG 102 Academic Writing
and Research 2
(previously completed ENG 111/112, 115/116 or 121
will be accepted)
CTA 100 Computing and Information
Technology
(formally CSI 112)
OR
CTP 103 Theories and Applications of
Digital Technology
(formally CTA 103)
*MAT 137 College Algebra
SOC 111 Introduction to Sociology
COM 111 Fund. of Oral Communication
OR
COM 116 Fund. of Oral Communication
for Non-Native Speakers
† This course has a prerequisite of BIO 101.
*MAT 145, 151, 191, or 230 satisfies MAT 137 requirement (former MAT courses 121, 131, 141, or 142 will also satisfy MAT 137 requirement).
BACKGROUND INFORMATION
Submit explanation of questions for which you answer "yes" and provide documents relating to your answer in
a sealed envelope and emailed to tdneall@aacc.edu or mailed separately to address on first page of this
application, ATTN: Tammie Neall.
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 e
ver 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 e
ver 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 e
ver 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.
I understand that by filling in my name below, it will be considered my signature.
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 the federal compliance officer and Title IX coordinator at 410-777-1239,
complianceofficer@aacc.edu
or Maryland Relay 711.
G:\ALHEALTH\HDrive\AHCOMMON\TDN\Applications IC approved FINAL 2021-2022\Word Copies\MLT Application 2021_IC Approved 12.01.2020.docx
Please review prior to submitting this application. This application must be completed in its entirety.
click to sign
signature
click to edit
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:
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.
September 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: MLT
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.
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 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
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
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.
g:\alhealth\hdrive\ahcommon\tdn\applications.ICapprovedFINAL2021-2022.addressverificationform.pdf
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Medical Laboratory Technician Program Application (Anne Arundel Community College)

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