National Board of Medication Therapy Management

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:

Signature arrow sign here


Signature Certificate
Document name: Employment Verification
lock iconUnique Document ID: dee44f66584526353671d75ff7e23bb74f1c44ee
Timestamp Audit
August 10, 2019 12:51 PM ESTEmployment Verification Uploaded by Dustin Thomas - dustin.thomas@nbmtm.org IP 68.205.198.44
January 12, 2022 11:16 PM EST 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 EST 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