Application for Admission

Old Dominion University
Medical Laboratory Science Program
(Deadline for the traditional program: February 1. Applicants for degree completion program accepted during the Fall or Spring semester.)

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Date Date * / MM / DD YYYY
Choose the program you are applying for:
Name Name * First Middle Last
UIN#
Date of Birth Date of Birth * / MM / DD YYYY
Please describe your gender *

Please describe your gender Male Female Gender neutral Prefer not to answer
Please describe your ethnicity *

Please describe your ethnicity Hispanic or Latino Not Hispanic or Latino Prefer not to answer
Please describe your race (more than one can be selected) *

Please describe your race (more than one can be selected) White Black or African American American Indian or Alaska Native Asian Native Hawaiian or other Pacific Islander Middle Eastern of Northern African (MENA) Prefer not to answer Other Other
Permanent Address Permanent Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Mailing Address (If different from above) Mailing Address (If different from above)
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Home Telephone Number Home Telephone Number - ### - ### ####
Cell Telephone Number Cell Telephone Number - ### - ### ####
Email
Please list the names and addresses of all colleges/universities attended in the space below (including ODU). Submit official transcripts to ODU Admissions. Additionally, please provide unofficial copies of all non-ODU transcripts directly to the MLS Program director via rchilds@odu.edu.
College/University
Address
Major
Dates Attended
List Additional Colleges/Universities, Degrees, Dates Attended: