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Employment Verification

Employment Eligibility Verification for BCMTMS™ Candidates
Instructions: The candidate is to complete Sections 1 to 3.		Note: You are being asked to complete this form 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		NBMTM ID


Section 2: Experience Details
Company/Organization
Job Title
City
Country
Full Time Status
From (mm/yyyy)
To (mm/yyyy) Leave blank if current job

Section 3: 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: This form is to be used only by BCMTMS™ Initial Certification; it should not be used for Recertification.

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

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Timestamp

Audit

August 10, 2019 12:51 PM EDT

Employment Verification Uploaded by Dustin Thomas - dustin.thomas@nbmtm.org IP 68.205.198.44

January 12, 2022 11:16 PM EDT

Document owner contact@nbmtm.org has handed over this document to dustin.thomas@nbmtm.org 2022-01-12 23:16:34 - 68.205.198.44

January 13, 2022 12:40 AM EDT

Document owner dustin.thomas@nbmtm.org has handed over this document to no-reply@nbmtm.org 2022-01-13 00:40:43 - 68.205.198.44