St. Luke’s School of Phlebotomy Application

First Name Last Name Phone Number Address City State Zip Code Email Date of Birth

Previous St. Luke's Phlebotomy Student Yes No

Current St. Luke's University Health Network Employee Yes No

If yes – what is your employee ID? If yes – what is your current position? If yes – where is your main work location? Previous Work Experience

When you successfully complete the program, what type of employment are you looking to attain? Full Time Part Time Per Diem/Reserve Undecided

Provide Two References with Full Name, Relationship, Phone Number, and Email Address (No Family Members). You will need to provide letters of reference if contacted by our program coordinator.

High School Information:

High School Diploma Type High School Diploma GED

Place Issued:

High School Name High School City High School State High School Country Date Issued

You will need to provide copy of diploma or GED to our program coordinator.

PPC

Program Session Selection: Session 1: JAN 10 - APR 1, 2022 (Tues - Thurs, 11 AM - 3 PM) Session 2: APR 18 - JUL 8, 2022 (Tues - Thurs, 4 PM - 8 PM) Session 3: AUG 29 - NOV 18, 2022 (Tues - Thurs, 11 AM - 3 PM)