Application for Admission
Educational Program for Specialist in Blood Bank Technology/Masters in Transfusion Medicine

Complete the following form to apply to the Specialist in Blood Bank Technology or Masters in Transfusion Medicine Program at UTMB.

To request further information about the program, please contact LeeAnn Walker by email lpwalker@utmb.edu, or phone (409) 772-9477.

* Required fields are marked with an asterisk.

Program Information
*Application for: SBB Certificate only   TRM-MS with previous SBB    SBB with TRM-MS   
* Program Start Date for SBB only:
* Program Start Date for TRM-MS:Fall   Spring    Summer;  
 
Contact Information
* First Name:
* Last Name:
* Street Address:
* City:
* State:
* Zip:
Home or Cell Phone:
Work Phone:
* Please enter at least one phone number.
 
* Email Address:
 
 
Other Personal Information
Please provide the information below. Disclosure of gender and ethnicity is optional, but is requested for federal grant reporting purposes.
 
* MT/MLS Certification #:
* SBB Certification # (TRM-MS only)#:
* Date of Birth:
(mm/dd/yyyy)
* U.S. Citizen?Yes   No
* Residence Card
or Student Visa?
Yes   No
Gender:Female   Male
Ethnicity:
 
 
Undergraduate Transcript Information
Please provide a complete record of your undergraduate education, including MT/MLS and SBB training, as applicable. Partial entries will NOT be recorded. Any entry including the institution's name requires all fields (excluding state) to be completed. Submit copies of all transcripts or transcript evaluations for initial review.
 
 Dates AttendedCollege or UniversityCityStateCountryDegree
FROM
mm/yyyy
TO
mm/yyyy
1.
2.
3.
4.
5.
6.
If you have additional education to disclose, you may enter this information on the next page. Please specify the number of additional entries:
 
* Major Field of Study:
Minor Field of Study:
 
 
Record of Experience
Start with your present or last position. If you have ever been employed under a different name, you must provide that name for each position to which it applies. Partial entries will NOT be recorded. Any entry including the employer's name requires all fields to be completed.
 
Name of Employer:
From (mm/yyyy):
To (mm/yyyy):
Street Address:
City:
State:
Supervisor:
Reason for leaving:

Characters remaining:
Job title and essential duties, tests and tasks performed in this position:

Characters remaining:
Percentage of time spent working in Blood Bank:
 
Name of Employer:
From (mm/yyyy):
To (mm/yyyy):
Street Address:
City:
State:
Supervisor:
Reason for leaving:

Characters remaining:
Job title and essential duties, tests and tasks performed in this position:

Characters remaining:
Percentage of time spent working in Blood Bank:
 
Name of Employer:
From (mm/yyyy):
To (mm/yyyy):
Street Address:
City:
State:
Supervisor:
Reason for leaving:

Characters remaining:
Job title and essential duties, tests and tasks performed in this position:

Characters remaining:
Percentage of time spent working in Blood Bank:
If you have additional experience to disclose, you may enter this information on the next page. Please specify the number of additional entries:
 
 
Professional References
List three persons from whom you will request a professional reference using the form supplied by UTMB (download here). All fields are required.
 
 Full NameFull AddressTelephoneOccupationEmail Address
1.
2.
3.
 
 
Emergency Contact Information
* Name:
* Relationship:
* Street Address:
* City:
* State:
* Zip:
Home Phone:
Work Phone:
* Please enter at least one emergency contact phone number.