National Board of Medication Therapy Management

Employment Verification (EVC1)


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:

National Board of Medication Therapy Management https://www.nbmtm.org
Signature Certificate
Document name: Employment Verification (EVC1)
Unique Document ID: 13e3e170ef86de60b10263a2a8e7ffb9945b600f
Timestamp Audit
August 10, 2019 12:51 pm EDTEmployment Verification (EVC1) Uploaded by The National Board of Medication Therapy Management - [email protected] IP 12.238.159.1