Please select your preferred location *

Adams
Lancaster/Lebanon
Franklin
York

Please read carefully, print or type clearly and complete in full.

Name *

Home Address *

1000

Phone *

Email *

Education

High School or its equivalent

School name

Scholastic Average

Highest Grade Completed

School mailing address

Major course or Subject

Degree

Business

School name

Scholastic Average

Highest Grade Completed

School mailing address

Major course or Subject

Degree

College

School name

Scholastic Average

Highest Grade Completed

School mailing address

Major course or Subject

Degree

Other

School name

Scholastic Average

Highest Grade Completed

School mailing address

Major course or Subject

Degree

Membership in Professional Organizations

Professional Licenses/Certifications

Number

Date Issued

Renewal Date

Professional Licenses/Certifications

Number

Date Issued

Renewal Date

Professional Licenses/Certifications

State

Number

Date Issued

Renewal Date

How were you referred to the WellSpan Phlebotomy Training Program?

1000

Please provide a brief history of your work experience to date.

1000

Briefly summarize any computer experience that you may have.

1000

Please list other languages that you are fluent in

1000

List your special qualifications, skills, accomplishments or community activities (some examples are: scholastic honors, offices held and activities in high school, college, skills with machines, public speaking and writing experience, and volunteer experience.) DO NOT list any organization that would reveal race, creed, religion, national origin, physical handicap, marital status or ancestry.

1000

Why are you interested in a career in phlebotomy?

1000

Provide a specific example of a time when you used good judgment and logic in solving a problem.

1000

Provide an example of a time when you used your communication skills to resolve a difficult situation.

1000

Please note that a conviction record will not necessarily prevent acceptance into the Phlebotomy Training Program. Such factors as nature of offense and other aggravating and mitigating circumstances will be considered.

Reference Forms

A reference form is included with this application. ONLY individuals familiar with your professional skills or work abilities should be used as references. If you have any formal post-high school education or training, one of your references must be affiliated with the school or be familiar with your current work activities.

Click here to download the reference form

Please return at least two completed reference forms to Amber Rayman-Saul
arayman-saul@wellspan.org.

Applicant's Statement

(please read before signing)

The following applicant statement is offered for your consideration:

The facts set forth in my application for the Phlebotomy Training Program are true and complete. I understand that false statements on this application may be considered cause for rejection of this application or for termination from the Phlebotomy Program at any time. I hereby authorize Wellspan Health to conduct work history, reference, or police record inquiries as it deems appropriate.

I understand that nothing contained in the program application or in the granting of an interview is intended to create a contract between Wellspan Health or its related organizations and myself. No promises regarding acceptance into the Phlebotomy Training Program have been made to me and I understand that no such promise is binding upon Wellspan Health unless made in writing and signed by the Program Coordinator. If acceptance occurs, I understand that I have the right to terminate my position in the program at any time and that Wellspan Health and related organizations retain a similar right.

If offered a position in the Phlebotomy Training Program, I consent to taking a complete pre-placement physical examination, including a drug screening test, and understand that my acceptance is contingent upon the results of the examination.

Signature *

Validation *

Date