National Board of Medication Therapy Management

Employment Verification (EVC2)


Employment Eligibility Verification for BCMTMS™ Candidates

Instructions:

  • The candidate is to complete Section 1.
  • The supervisor completes Sections 2 to 4.

Note to Employer: You are being asked to complete this form for an employee or former employee who is a candidate for the BCMTMS™ Examination. Each candidate must document 2 years of direct practice experience in medication therapy management.

 

Section 1: Candidate Information

Salutation

First Name

Middle Name

Last Name

Suffix

 

 

 

 

 

Address

 

City

State, Zip

Country

  

 

 ,    

   

Phone Number

Email Address

Job Title

   

     

 

 

NBMTM ID

 

Facility Where Experience was Acquired

 

 

   

Do you have more than 2 years of MTM experience?

☐ Yes

☐ No

     
 

Section 2: Employer or Authorized Representative

Company/Organization

City, State

 

Country

  ,     

Full Time Status

 
               
 

Section 3: Experience Details

From (mm/yyyy)

 

To (mm/yyyy)
Leave blank if current job

 
 

Section 4: Signature Disclaimer

By signing below, I certify that the information listed here is true and correct to the best of my knowledge and that I have personally verified them for accuracy. I am aware that my inaccurate or false representation may lead to penalties, including, but not limited to, NBMTM’s refusal to accept further verification from me.

For Self-Verification: In addition, I understand that if I am the candidate listed above and signing this form because I am in private practice, or I am unable to obtain verification of my employment, my inaccurate or false representation may lead to penalties including, but not limited to, revocation or denial of my certification, recertification, or eligibility for certification.

Please Note:

  • Candidates should submit only as many forms as needed to verify 2 years of MTM experience.
  • This form may be duplicated if needed for more than one employer.
  • Candidates in private practice may sign their own form. Proof of ownership/partnership in a private practice is required.
  • This form is to be used only by BCMTMS™ Initial Certification; it should not be used for Recertification.

Supervisor’s Name (or Candidate’s Name if self-certifying)

Supervisor’s Title

Relationship to Candidate

      N/A Self

Leave this empty:

National Board of Medication Therapy Management https://www.nbmtm.org
Signature Certificate
Document name: Employment Verification (EVC2)
Unique Document ID: 26c1127a562033f37e7f4fa47ee7c134478e04a3
Timestamp Audit
August 12, 2019 6:15 am EDTEmployment Verification (EVC2) Uploaded by The National Board of Medication Therapy Management - [email protected] IP 50.89.16.212