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Phlebotomy Program Application Form


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


High School or its equivalent




Membership in Professional Organizations
Work Experience
Other Qualifications and Skills

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 Edwin Beitz

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.


If you do not recieve a confirmation email after submitting please contact phlebotomytraining@wellspan.org to receive an application via email.