Certified Phlebotomy Technician


APPLICATION FOR CERTIFICATION AS A
CERTIFIED PHLEBOTOMY TECHNICIAN
CPT (ACA)

[You will need to also download the PB/PCT proctor application for on site testing]

Print or Type your name exactly as you want it to be on your certificate.

Last Name First Name Middle Initial

Information and Instructions to Applicant

  1. Please type or print all information except where signature is required

  2. Please check the eligibility requirements for certification below

  3. Before submitting this application, make sure you have provided the following:

            _____  $100.00 Application Fee (Must accompany the application or it will not be processed)
            _____  Proof of high school graduation or equivalent
            _____  If applicable, official final transcript stating graduation from phlebotomy school, college or training program
            _____  If applicable, copy of state license or other phlebotomy certification
            _____  Application signed and dated by applicant and necessary instructors and supervisors

  1. Application must be completed, signed and received at least 15 days before the scheduled examination date

  2. All applications are subject to content verification and approval

  3. Ineligible applicants will be refunded the examination fee minus a $35.00 processing fee

  4. No refunds will be made for no-shows on the exam date

  5. You will receive notification upon approval of this application, informed of schedules examination site, receive study guide and content outline.

ELIGIBILITY REQUIREMENTS FOR CERTIFICATION

  1. Applicant must be a graduate of an accredited high school or equivalent
  2. Applicant must meet one of the following requirements (check on box)

                    A.        Completed at least one year of work experience using phlebotomy skills
                    B.   
     Successful completion of a formal program (e.g. phlebotomy, laboratory assistant, medical assistant, EMT, nursing,
                                        etc.) which includes didactic instruction and a minimum of 100 clinical hours. Must show documentation of at least
                                        100 successful venipunctures and 10 skin punctures.
                    C.   
     Have a current, valid certification obtained by an examination from another certification agency or society approved
                                        by ACA. These applicants will be considered for ACA certification without taking another exam. Recertification
                                        requirements must be met.

  1. All applicants applying under 2A and 2B must take and pass the ACA examination for Certified Phlebotomy Technician (CPT)

PART I.

Full Name

Social Security Number
Street Address City State Zip
Home Phone Number Work Phone Number
Email Address

PART II.

A. Secondary

Senior High School

Dates Attended
Address

Date Graduated
G.E.D.

Date City/State

A. College or University

Name/Complete Address Dates Hrs. Completed Degree

C. Phlebotomy Training

If applicant is currently in school or training program, this section must be completed by a proper school official to verify training and successful completion of the course. The applicant's final transcript must be provided.

Applicant Name

Birthdate
School Name

Program Name

Tele. No:

School Address

Course Date From

Course date To

I hereby certify that the applicant named above did (or will) satisfactorily complete the entire formal program which included didactic instruction and a minimum of 100 hours of clinical experience. I recommend this applicant as a qualified candidate for certification as a Certified Phlebotomy Technician of the American Certification Agency.

Official Signature

Date
Ttile/Position

 

PART III. EMPLOYMENT EXPERIENCE

Approved Phlebotomy Experience

All approved phlebotomy experience credited towards certification must be earned in an approved healthcare facility such as a hospital, physician office laboratory, independent laboratory, HMO, group practice, etc.

1. Facility

Facility Address

Employment  Date From (Mo & Yr)

Employment  Date to (Mo & Yr)

Position Held Supervisor Name Telephone Number

 

2. Facility

Facility Address

Employment  Date From (Mo & Yr)

Employment  Date to (Mo & Yr)

Position Held Supervisor Name Telephone Number

 

3. Facility

Facility Address

Employment  Date From (Mo & Yr)

Employment  Date to (Mo & Yr)

Position Held Supervisor Name Telephone Number

 

PART IV. RECOMMENDATION FOR CERTIFICATION

If applicant is currently employed, please have supervisor or manager sign this recommendation for certification.

Signature/Title

Date

Street Address City State Zip

 

PART V. OPTIONAL SCORE RELEASE

Some educational institutions and/or state licensure boards request applicants' examination results. To grant permission for your results to be eligible for release if requested, sign the release authorization below. Signing this release is VOLUNTARY and will not affect the outcome of your examination in any way. If you DO NOT want your results released, DO NOT SIGN THE AUTHORIZATION. I hereby authorize the American Certification Agency for Healthcare Professionals to release my examination scores:

Applicant's Signature

Date

 

PART VI. AGREEMENT

I hereby give my authorization to the American Certification Agency for Healthcare Professionals  to request necessary information from individuals, institutions and/or organizations named herein to validate information for certification. I certify that the information given  herein is true and correct, to my knowledge and belief, and realize that certification is subject to revocation for misrepresentation. If accepted as a certificant, I agree to uphold and abide by the Standards of Practice and Bylaws of the American Certification Agency for Healthcare Professionals.

Applicant's Signature

Date


Do not write in space below


 

Date application received            /              /            Date completed          /           /          Approved by  ____________                    

Application rejected by                        Reason                                                                      Date notified          /           /_____     

 

Exam Date

 

    Test Series

 

     Exam Site

 

         Proctor

 

    Exam Score

 

      Fee Paid

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Birth date                                                                     Social Security Number  ____________________________                                                              

GRANTED CERTIFICATE #                                            ISSUE DATE   ____________________________________                                                                              

RECERT DATES    ___________________________________________________________________________________




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Pins available for Phlebotomy, ECG and Patient Care Technicians
$10.00 (Includes S&H)
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