Employment Verification (EVC2)
Employment Eligibility Verification for BCMTMS™ Candidates
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
Facility Where Experience was Acquired
Do you have more than 2 years of MTM experience?
Section 2: Employer or Authorized Representative
Full Time Status
Section 3: Experience Details
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.
Supervisor's Name (or Candidate's Name if self-certifying)
Relationship to Candidate
Leave this empty:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: Employment Verification (EVC2)
Agree & Sign