Medical Lab Selection Request Form

Name*

First NameLast Name

Student ID*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

WGTC Email*

example@student.westgatech.edu

Did you attended the mandatory competitive selection informational session?

YesNo

Review your Self-Service Web student information and indicate your current residency status:*

Are you in good academic standing with WGTC? (Required)*

YesNo

Have you submitted an official transcript from each college previously attended?*

YesNo

Select Campus*

Murphy - May 1 application Deadline

The Medical Laboratory Technology program requires the following courses to be completed by the application deadline. Each course must be completed with a minimum grade of C. In addition to earning a minimum grade of C in each course, an overall GPA of 2.5 or higher must be earned in the required courses. Specific technical, science, and Health Science courses must be completed within seven years of the start of the program cohort start date.

Please identify where and when each course was completed, and the letter grade attained. If you repeated a required course, please list information relative to the highest grade achieved. WGTC must have an official transcript on file for each college previously attended. Please view your WGTC academic history through Self-Service BANNER Web to find the dates and grades for specific courses completed with WGTC.

Required Courses. (If you did not take the class, please type "NA" in the fields.) *

	College Where Completed	Date Completed	Letter Grade Earned
BIOL 2113
BIOL 2113L
BIOL 2114
BIOL 2114L
CHEM 1211 AND
CHEM 1211L OR
CHEM 1151 AND
CHEM 1151L

Bonus Points

Possible Bonus Points (maximum 3)

Submit an employer letter on company letterhead, including dates of employment, job title, and a brief description of duties for consideration.

One (1) point for six months of healthcare clinical work experience.
Clinical experience is defined as performing the duties as a Phlebotomist, Medical Laboratory Assistant, or Specimen Processor in a hospital, clinic, or physician’s office.
Two (2) points for six (6) to twelve (12) months of work in the healthcare field as a Phlebotomist, Medical Laboratory Assistant, or Specimen Processor in the clinical laboratory.
Three (3) points for more than one year equivalent of full-time experience as a Phlebotomist, Medical Laboratory Assistant, or Specimen Processor.

Please choose from the following:

1 Bonus Points: Completed six months of healthcare clinical work experience. Clinical experience is defined as performing the duties as a Phlebotomist, Medical Laboratory Assistant, or Specimen Processor in a hospital, clinic, or physician’s office.2 Bonus Points: Complete six (6) to twelve (12) months of work in the healthcare field as a Phlebotomist, Medical Laboratory Assistant, or Specimen Processor in the clinical laboratory.3 Bonus Points: Completed more than one year equivalent of full-time experience as a Phlebotomist, Medical Laboratory Assistant, or Specimen Processor.

Please Upload Proof of Bonus Points

I understand that this request, along with supporting transcripts, test results, or licenses, must be received by the application deadline. I also understand that meeting the minimum requirements does not guarantee selection as there are a limited number of seats available.

Your student email address is the primary communication method; it is important to check it often for updates and important information about your competitive selection application

Date*

Date

Signature*