Payment for MTM recertification

Please review your contact information record and update if necessary.

Country*

Street Address (line 1)*Street / PO Box

Street Address (line 2)Suite / Apt# / Floor

City*

State*

Province/Territory

Zip Code*

Postal Code

Phone number*

Country Calling Code*For international numbers, please also indicate country codes.

Phone Number*

Where did you graduate from?*

United States
Canada
Other

Pharmacy School Name*

Country of Pharmacy School*

Pharmacy School Name*

Write here*

Pharmacy School Name*

Write here*

Type of Degree Awarded*

Year Awarded*

Do you have any additional postgraduate degree?

Yes
No

Additional Postgraduate Degrees (if applicable)*

Select Others to enter additional degree

Write here*

Select ONE of the following

Please note, only ONE of the following items is required for board eligibility*

You must complete two (2) years of practice experience, post-licensure, with experience in medication therapy in retail pharmacy, community pharmacy, or ambulatory care pharmacy.
Experience can be waived if the applicant successfully completes an NBMTM-approved training program in medication therapy management. Approved training programs are:

⚪ APhA’s Delivering Medication Therapy Management Services Certificate Training Program.
⚪ Power-Pak C.E.® Certificate Program in Medication Therapy Management.
⚪ University of Florida’s graduate certificate in Comprehensive Medication Management (CMM).
⚪ University of Florida’s Master’s degree in Medication Therapy Management.
⚪ University of Southern California’s Advanced Practice Pharmacist Certificate in Comprehensive Medication Management.
⚪ Residency in medication therapy management or ambulatory care pharmacy (PGY-1 or PGY-2).

I have professional experience in medication therapy management as defined by the NBMTM.
I have completed a training course in medication therapy management.
I have a postgraduate degree in medication therapy management.
I have completed a pharmacy residency program.

For those who own their pharmacy/business, or those who do not have access to their supervisors, or are not comfortable with us reaching out to their supervisors, you have the option to sign an employment verification attestation form. Keep in mind, NBMTM will periodically audit these forms to ensure the integrity of our candidates.*

I would like to self-certify my employment verification attestation form.
I would like NBMTM to verify my employment directly with my employer.

Employer Name*

Job Title*

Full-Time Position?*

Yes
No

Answer "Yes" if you work at least 30 hours per week

Country*

Write here*

State/Province/Emirate*

City*

Supervisor's Name*

Supervisor's Email (must be company email)*

Supervisor's Phone Number*

Current Employer?*

Yes
No

Employment Begin Date*

Employment End Date

Would you like to add another employer?*

Yes
No

Employer Name*

Job Title*

Full-Time Position?*

Yes
No

Answer "Yes" if you work at least 30 hours per week

Country*

State/Province/Emirate*

Write here*

City*

Supervisor's Name*

Supervisor's Email (must be company email)*

Supervisor's Phone Number*

Current Employer?*

Yes
No

Employment Begin Date*

Employment End Date

Would you like to add another employer?*

Yes
No

Employer Name*

Job Title*

Full-Time Position?*

Yes
No

Answer "Yes" if you work at least 30 hours per week

Country*

State/Province/Emirate*

Write here*

City*

Supervisor's Name*

Supervisor's Email (must be company email)*

Supervisor's Phone Number*

Current Employer?*

Yes
No

Employment Begin Date*

Employment End Date

Training Course in Medication Therapy Management*

Write here*

Institution that granted your postgraduate degree in medication therapy management*

Write here*

Pharmacy Residency Program

Medication Therapy Management (MTM)
Ambulatory Care Pharmacy

Name of Institution of Pharmacy Practice Residency*

Provide your pharmacist license information

American with Disabilities Act

In accordance with the American with Disabilities Act (as amended), it is the policy of NBMTM to provide accommodations in testing conditions to applicants with disabilities who are qualified candidates for our certification examination to the extent such accommodations are requested on a timely basis, reasonable, not unduly burdensome, consistent with the nature and purpose of the examnination and necessitated by the applicant’s disability.
Documentation is required for all special accommodations.

Do you require special accommodations due to medical disability?*

No
Yes. I will provide medical documentation to support my request.

When would you like to upload your supporting documents?

When would you like to upload your supporting documents?*

Now
Later

Upload your employment certification for employed or self-employed applicants*

Download the employment verification form here.

Upload proof of completion of MTM training program*

Upload a copy of your Master’s degree in Medication Therapy Management*

Upload proof of completion of residency in medication therapy management or ambulatory care pharmacy*

Upload your pharmacist license(s)*

Provide a copy or online printout of your pharmacist license(s)