Name of company Address Phone
Position Immediate Supervisor
Background / Personal History Requirement: After admission to the AAS-SLT program and prior to enrollment into internship
courses, a personal history statement will be required. This statement requires truthfully answering the following five questions:
1. Have you been issued a citation or summons for, or has/have warrants(s) been issued against you related to, or have you
been arrested, charged with, arraigned, indicted, convicted of , pled guilty/”no contest”/nolo contendere/”best interest of” or any
similar plea to ; or been sentenced for any criminal offense, including all misdemeanors and felonies in any state or other
2. Have you been discharged from the military on ground(s) other than a honorable discharge?
3. Have you been diagnosed with, do you have, or have you had a medical, physical, mental or emotional or psychiatric condition
that might affect your ability to safely practice as a science laboratory?
4. Have you had a problem with, been diagnosed as dependent upon, or been treated by mood-altering substances, drug or
5. Have you been diagnosed as dependent upon/addicted to, or been treated for, dependence upon medications?
I have read the above and understand that I will be required to answer the five aforementioned questions after I am admitted to the
Write a brief paragraph describing your reasons for Chemical Technology as a career, and for selecting the Delgado Community
College Science Laboratory Technology Program. What are your professional plans/aspirations?
I certify that the answers I have given to each and all of the foregoing questions are true to the best of my knowledge. I know that
falsification of any information on this form may adversely affect my admission to the AAS-SLT Program.
Please keep this office informed of any changes in the information submitted on this application. Thank you.
Incomplete admission packages will be returned