Laboratory Assistant Program (CAS) Phlebotomy (Advanced Skills Set)
Request form for admission to Laboratory Assistant or Phlebotomy Programs
Email address *
Are you a Pierpont Student (Note: This program is restricted to Pierpont students.)
Today's Date
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First and Last Name
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Date of Birth (DOB)
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Student E-mail (if available)
Best Phone Number
Are you interested in Phlebotomy Only? Please note that skill sets are not financial aid eligible.
Semester you wish to start
Desired Campus Location (choose one)
Current GPA
Total Credit Hours Completed
Current Major
Self-Reported Courses Completed
(select the grade for the corresponding completed classes. If you have not taken a class leave that row blank)
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B
C
D
F
Credit
HLCA 1100 3 cr.
HLCA 1101 1 cr.
HLCA 1102 3 cr.
HLCA 1170 3 cr.
HLCA 1171 1 cr.
HLCA 1200 3 cr.
HLCA 2200 3 cr.
ENGL 1104 3 cr.
ENGL 1108/9 3 cr.
INFO 1100/OFAD 1150 3 cr.
STATEMENT | SIGNATURE My signature (type your name below) attests that the information contained on this sheet is true (to the best of my knowledge) AND if admitted after meeting the admissions requirements, I permit my academic major to be changed to Laboratory Assistant (0807) or to Phlebotomy, whichever is applicable.
Today's Date
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A copy of your responses will be emailed to the address you provided.
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