New Phlebotomy Technician Program

Butte County Career Technical Education Center

2491 Carmichael Dr #500, Chico, CA 95928

Phlebotomy Technician Program

Instructions:

This application must be completed electronically (hand written applications will not be accepted).
Application packet must include:
 Completed Application
 Verification of high school diploma or equivalent

First Name

Middle Name

Last Name

Street

City

State/Province

Zip/Postcode

Cell Phone

Home Phone

Ethnicity

Gender

Birth Date

Social Security No

Native Language

How did you find CTEC-ROP?

Have you applied for a CTEC-ROP class previously?

Yes No Not Selected

Have you ever taken an CTEC-ROP class?

Yes No Not Selected

If yes, what class?

Currently employed?

Yes No Not Selected

Letter of Reference

optional and recommended

Primary Educational Goal

Secondary Educational Goal

Emergency Contact Information:

Contact Name

Relationship

Cell Phone

Home Phone

Work Phone

Disability

Yes No

Disability Description

Learning Difficulties

Yes No

Learning Difficulties Description

Education:

Please list schools attended. Attach a separate sheet of paper if necessary.

Years of School Completed

Highest degree or diploma

Most School Years Completed Outside US

Yes No Not Selected
Flag if most school years were completed out US - e.g.

Degree or Diploma Earned Outside US

Yes No Not Selected
Flag if degree or diploma was earned outside US - e.g.

Verification of high school diploma or equivalence

PDF or Word Files Only

Is this your first time enrolling in college

Yes No Not Selected

How many years in school?

example: high school = 12 years

High School Name and Location

Area of Study or Relevant Course Work

Diploma or Degree

Yes No Not Selected

Dates Attended

MM/DD/YYYY - MM/DD/YYYY

Are you applying within 12 months of graduating from High School?

Yes No Not Selected

Vocational Training Name and Location

Diploma or Degree

Yes No Not Selected

Area of Study or Relevant Course Work

Dates Attended

MM/DD/YYYY - MM/DD/YYYY

College/Other Name and Location

Area of Study or Relevant Course Work

Dates Attended

MM/DD/YYYY - MM/DD/YYYY

Work Experience:

Include paid and volunteer experience. Please attach a separate sheet if necessary. Related experience may not be a requirement for admission; however, we seek individuals who are motivated and understand the employment conditions of the occupation.

Work Experience

Employer or Organization Name

Employer or Organization Address and Telephone Number

Job Description

Dates of Employment

MM/DD/YYYY - MM/DD/YYYY

Reason For Leaving (if applicable)

Employer or Organization Name

Employer or Organization Address and Telephone Number

Job Description

Dates of Employment

MM/DD/YYYY - MM/DD/YYYY

Reason for Leaving (if applicable)

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I declare that the information and documents submitted in conjunction with this application are true and correct to the best of my knowledge and that I composed my personal statement by myself. I acknowledge that i t is my responsibility to notify CTEC of any subsequent changes regarding information provided. I understand that obtaining a license or certification may require a background check.

Signature of Applicant

Date

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Butte County CTEC does not discriminate on the basis of race, color, national origin, age, religion, political affiliation, gender, mental or physical disability, sex orientation, genetics, or any other basis protected by federal, state or local law, ordinance or regulation, in its educational program(s) or employment.

Personal Statement:

Please answer the following questions.

1. Why do you wish to take this program?

2. What personal qualities will you bring to this profession?

3. Describe how you have participated on a team.

4. Why did you leave your last job or school?

5. What are your hobbies and interests?

6. List all reasons you find acceptable for absences from work and school.

7. Give an example of a recent goal you set and achieved.

8. List any questions you have about the class.

Personal Characteristics & Requirements

Fall class begins September 5, 2023, and meets on Tuesday and Thursdays from 3:00pm to 6:00pm for 11 weeks. During the last 6 weeks students complete an additional 40-80 hours of clinical training and are required to complete 50 successful venipunctures, 10 successful skin punctures and observe two arterial draws. Per our approval with the State of California, one hundred percent attendance is required.
Please click here for Personal Characteristics

Signature of Applicant

I have received and agree to the job requirements provided in the Personal Characteristics & Requirements document for this program.

Date

Payment Information

Items	Amount
Tuition	$0.00
Total	$0.00

Payment Method

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Phone Number

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CardHolder Name

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CardHolderID / RIF

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Credit Card Number

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Expiration Date

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Security Code

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Currency

USD

Account Number

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Routing Number

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