NAACLS Program Official Form with Payment

Please note this form is not intended for:

- Individuals associated with a new program applying for Accreditation. For Initial Programs, please follow the instructions in the NAACLS Application Packet.

- Individuals who have been approved by NAACLS in the past. If this is the case, please complete the demographic pages of the Program Official Approval Form, the NAACLS approval letter, a current CV, and a narrative explaining the changes (eg –assuming the role of another NAACLS accredited program at this institution or another institution). A single PDF document of the aforementioned documents should be submitted to POForms@naacls.org.. Since the applicant has been approved previously, the application fee is waived.

Prior to completing this form, please complete all information in one of the linked forms below. We will request you upload the form and all attachments in 1 pdf below.

Medical Director Approval Form
Program Official Approval form

1. The applicant is applying for the following Program(s) Type (check all that apply) *This question is required.

Space Cell	CG	DMS	HT	HTL	MLA	MLM	MLS	MLT	PathA	PHLEB	PHM
.	.: CG	.: DMS	.: HT	.: HTL	.: MLA	.: MLM	.: MLS	.: MLT	.: PathA	.: PHLEB	.: PHM

2. Sponsor / Institution Information

Name *This question is required.

Sponsoring Institution City *This question is required.

Sponsoring Institution State *This question is required.

Sponsor Type *This question is required.

3. Information regarding the individual completing this form:

The individual completing this form is the Program Official looking to be approved via this form *This question is required.

Your Role at the Sponsoring Institution/Program: *This question is required.

Please enter an 'other' value for this selection.

Contact information if individual completing form is not the applicant

Space Cell	Prefix	First Name	Middle Initial	Last Name	Credentials
-	-: Prefix	-: First Name	-: Middle Initial	-: Last Name	-: Credentials

Email address if individual completing form is not the applicant *This question is required. This question requires a valid email address.

Phone Number if individual completing form is not the applicant This question requires a valid number format.

Phone number extension This question requires a valid number format.

4. Applicant is applying for one of the following: *This question is required.

Permanent status
Temporary status

5. Name and credentials of Program Official applicant

Name *This question is required.

Space Cell	Prefix	First Name	Middle Initial	Last Name	Credentials
-	-: Prefix	-: First Name	-: Middle Initial	-: Last Name	-: Credentials

City *This question is required.

State / Province *This question is required.

Country *This question is required.

Email (please note this email will be sent a copy of this form once complete) *This question is required. This question requires a valid email address.

Primary Phone Number *This question is required.

Primary Phone Number Extension This question requires a valid number format.

Secondary Phone number

Secondary Phone Number Extension This question requires a valid number format.

6. Other names the applicant's transcripts, certifications, etc may come through as :
(to allow NAACLS to tie the paperwork to this submission)

Space Cell	Prefix	First Name	Middle Initial	Last Name	Credentials
1	1: Prefix	1: First Name	1: Middle Initial	1: Last Name	1: Credentials
2	2: Prefix	2: First Name	2: Middle Initial	2: Last Name	2: Credentials
3	3: Prefix	3: First Name	3: Middle Initial	3: Last Name	3: Credentials

7. Upload an Approval Form and related documentation below. Please condense all files into one (1) pdf.
If you have not yet downloaded the instructions with application form, please do so here:
Medical Director Approval Form
Program Official Approval form

We have heard from some users that this button is taking multiple clicks to function.
Please click several times if it does not open immediately. We are working with support. thank you *This question is required.

File: {{filename}} delete

8. If required for position (see form), applicant is ASCP-BOC certified in the appropriate discipline & has primary source verification sent to POForms@naacls.org.

Verification by ASCP-BOC; use ascp.org and click on “verification"

9. If required for position, applicant's official college transcript for highest degree earned will be sent electronically to NAACLS from the primary source (POforms@naacls.org).

10. Upon completion of this form, I assert that all information is true to the best of my knowledge and agree to do the following:
Pay the $200 application fee on the next page
Have required letters, transcripts, and certification verification sent to POForms@naacls.org

Misrepresentation of information will negatively affect the accreditation status of the program and may lead to withdrawal of accreditation.
Application fees are nonrefundable. *This question is required.

I agree – $200.00