MECC Phlebotomy Application Applying for: * RequiredSummer Semester (deadline April 15)Fall Semester (deadline July 15)Both Fall and SummerName First Last Student ID * Required Student User Name Street Address City State / Province / Region ZIP / Postal Code Home PhoneCell PhoneType of Current CPR Card (provider and course) Date CPR Card Expires - must be mm/dd/yyyy format MM slash DD slash YYYY Upload Copy of CPR Card Here:Max. file size: 50 MB.High School Name: Date Graduated or GED Completed: Please upload a copy of your high school diploma or GED certificate and have an official high school transcript sent to MECC's Enrollment Services.Max. file size: 50 MB.Have you completed three Hepatitis B vaccinations? Yes No Please upload documentation of your HEP B vaccines.Max. file size: 50 MB.Are you a medical professional? Yes No Please upload a current copy of certification or licensure.Max. file size: 50 MB.Educational HistoryColleges AttendedDates AttendedDegrees Received Have you been convicted of a felony involving a sexual crime OR have you ever been convicted of any other felony under the laws of Virginia or of the United States within the last five (5) years? Yes No Official SignatureNameDate I understand that all information on this application is subject to verification and I consent to a criminal history background check and drug screen. I understand that falsification of any portion of this application may be reason for my withdrawal from the phlebotomy program. I certify the above stated information is accurate to the best of my knowledge.