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

Please type or print all information except where signature is required
Please check the eligibility requirements for certification below
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

Application must be completed, signed and received at least 15 days before the scheduled examination date
All applications are subject to content verification and approval
Ineligible applicants will be refunded the examination fee minus a $35.00 processing fee
No refunds will be made for no-shows on the exam date
You will receive notification upon approval of this application, informed of schedules examination site, receive study guide and content outline.

ELIGIBILITY REQUIREMENTS FOR CERTIFICATION

Applicant must be a graduate of an accredited high school or equivalent
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.

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 ___________________________________________________________________________________