Application Form
Susquehanna Health Clinical Laboratory Science Program
777 Rural Avenue, Williamsport, PA 17701
First Name MI Last Name Social Security #
School Address School Phone
Home Address Home Phone
E-Mail Address
At Which Location Are You Most Easily Reached? School  Home
High School SAT:  Math   Verbal 
College Year    GPA 
Please List Previous Employer(s) or Volunteer Work
Employer Type Work Hours/Week Dates
Employer Type Work Hours/Week Dates
Employer Type Work Hours/Week Dates
Please List Activities, Honors or Scholarships Awarded
Please Write a Paragraph Describing Your Reasons for Choosing Clinical Laboratory Science as a Profession
and Your Goals Upon Completion of the Clinical Year