MLS Program Application

Name

First NameLast Name
Current Mailing Address

Street Address

Street Address Line 2
CityStateZip Code
Is your permanent home address different than your mailing address?
Permanent Address

Street Address

Street Address Line 2

CityState

Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Place of Birth
Are you a citizen of the United States?
Have you ever been convicted of a felony?
Nearest Relative
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code

Education & Work History
Name of High School
Graduation Date
Name(s) of college/university and dates attended
College Major
Type and date of degree, if applicable
Choose one:
Please list all of your work experience.

References

Please list names of references with addresses. Do not list relatives.
Faculty Reference

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Business/Professional Reference

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Zip Code

If you are accepted into the program, do you anticipate the probability of remaining in this region in your professional work?
Preferred Admission Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date Pre-Medical Technology Courses Will Be Complete

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Why do you wish to become a medical technologist? What personal qualifications do you have which you believe would be an asset in this profession?

Additional Steps
After submitting this application, you must:
1. Send an official copy of your transcript(s) to:
  - Cynthia Holman, Medical Laboratory Science Program Director, North Mississippi Medical Center, 830 S Gloster St, Tupelo, MS 38801
  - or email to cholman@nmhs.net
2. Ask your references to submit the recommendation form.
3. If your degree will include a year at our Medical Laboratory Science Program, have the university send NMHS an official letter stating that you have completed all required pre-medical technology courses and that a BS degree will be granted by that university on completion of the year in our program.
4. Students who complete a degree in a foreign country must submit a transcript evaluation verifying US Baccalaureate degree equivalency. A list of agencies will be provided on request.
Acknowledgement
Should be Empty: