Certificate/City/State B. College / Medical Laboratory / Certified Medical Laboratory / /
Person
FINAL TRANSCRIPT / / /
Position
driver / OFFICIAL / Supervisor / Technician / Supervisor Phone Number Fax number Supervisor / Assistant / Director of Testing and Competency Assurance / test administrator / Medical Technologist / Registered Dental Assistant / Certified Medical Administrative Specialist / Registered Medical Assistant / /
Application for Certification Type or print information clearly and legibly, using blue or black ink, AS IT APPEARS on your driver’s license, passport, or state/military-issued ID card. This information MUST match d