National Board of Medication Therapy Management

Employment Verification

Employment Eligibility Verification for BCMTMS™ Candidates


  • 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


First Name

Middle Name

Last Name









State, Zip






Phone Number

Email Address





Section 2: Experience Details



Job Title




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:

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Signature Certificate
Document name: Employment Verification
lock iconUnique Document ID: dee44f66584526353671d75ff7e23bb74f1c44ee
Timestamp Audit
August 10, 2019 12:51 PM EDTEmployment Verification Uploaded by Dustin Thomas - IP
January 12, 2022 11:16 PM EDT Document owner has handed over this document to 2022-01-12 23:16:34 -
January 13, 2022 12:40 AM EDT Document owner has handed over this document to 2022-01-13 00:40:43 -