Instructions and APPLICATION for ASCP Board of Certification for Phlebotomy Technician (PBT)

Important:
Carefully review the ASCP Board of Certification Procedures for Examination and Certification Booklet to ensure that you meet the eligibility requirements before you begin completing the application form. This booklet is available on the ASCP website at www.ascp.org/certification. The Board of Certification does not establish eligibility of any candidate from information that is supplied via e-mail, correspondence or telephone calls alone. Our office must base all decisions on a review and verification of information supplied through formal application for examination. Email Address (Required if available) Indicate your e-mail address in the space provided. Please print clearly. Home Street Address, City, State, Zip Code (Required) Enter your complete mailing address. Birth Date (Required for identification purposes) Print the month, day and year as shown in this example. July 2, 1985 0 7 0 2 1 9 8 5 Gender (Required) Indicate F for female and M for male.

Detach these instructions (pages 1& 2) from the application form.

Step 1: Examination Route (Required) Review the eligibility requirements on page 5 of the Procedure Booklet to determine the examination route under which you are applying. Indicate the route number in the space provided. Have you applied previously for this same examination category? If yes, indicate the month and year of application. Step 2: Personal Information Social Security Number Enter the last four digits of your social security number in the space provided. If you are Canadian, DO NOT include your social insurance number. Leave the space blank and a number will be assigned to you. If you do not have a U.S. social security number, leave the space blank and a number will be assigned to you. Daytime Telephone Number (Required) Enter a telephone number where you can be contacted during regular business hours, including area code and extension. Indicate home or office. Salutation, Last Name, First Name, Middle Initial, Maiden Name (Required) Print your full name in the space provided. Your first and last names, as printed on the application form, must match your name on your drivers license and identification.

Ethnicity (Optional) Print one of the following numbers in the box. 1. Caucasian 2. African American 3. Asian or Pacific Islander 4. Hispanic 5. Native American 6. Other Step 3: Are you certified by the ASCP Board of Certification in another examination category? If so, indicate the category and your certification number as shown below: Category M L T Certification Number Category C 8 9 0 1 2 3 4 5

Certification Number

Step 4: Phlebotomy Training Program Information [See PROCEDURE BOOKLET page 19] If you are applying for examination under Routes 3 or 5, skip to Step 6. Route 1 If you have completed a NAACLS approved phlebotomy training program (Route 1), check the appropriate box and fill out all requested program information: name of institution, address, name and phone number of Program Director and program dates (the date the program started and the date the entire program ends both classroom and clinical portion). The school code number MUST also be indicated. See your Program Director for this information. If you have completed a California Dept. of Public Health approved phlebotomy program (Route 1), check the appropriate box and fill out all requested program information as indicated.

The information contained in this application form is subject to change without notice.

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Download the training documentation form (PDF) located at www.ascp.org/licensure. This form must be completed by your program official and attached to a Letter of Authenticity*, on letterhead signed by the program official verifying the accuracy of the information on the form. If you are applying for California Licensure you must also include the release form (PDF) located at www.ascp.org/licensure.
*Letter of Authenticity must be submitted from your program official with the appropriate training documentation form. The Letter of Authenticity must be printed on original letterhead, state that the training documentation form was completed by your program official and include the date and your program officials signature.

Review the information you have provided in each section of the application. Is it accurate and complete? If the application is complete, read the pledge on the back of the application form and sign and date the application. Unsigned applications will be returned to you. Faxed applications are not acceptable. Step 9: Payment Information [See PROCEDURE BOOKLET page 3] Enclose a check/money. Please DO NOT fax the application form. Faxed applications are not acceptable.

Route 2 If you have completed a two-part formal, structured phlebotomy program (Route 2), check the appropriate box and fill out all requested program information as indicated. A training documentation form must be downloaded from the website at www.ascp.org/certification under Step 2, Verify Your Training. Forward this form to your Program Director for verification of your training. A completed training documentation form along with a letter from your Program Director, on official letterhead, verifying authenticity must be submitted with your application. (Printed training documentation forms are available upon request.) Your application will not be processed without the training documentation form(s) and letter(s) of authenticity attached. Route 4 If you have completed another allied health program (Route 4), check the appropriate box and fill out all requested program information as indicated. A notarized copy of your current state/provincial license for RN or LPN, or a notarized copy of a certificate of completion from the accredited allied health program you completed MUST be included with this application. Step 5: Academic Education (Required) Provide the information requested about your high school education. Step 6: Employment Information [See PROCEDURE BOOKLET page 18] If work experience is required to establish your eligibility under the route you have selected, complete this section, indicating your present employment information, your total experience in phlebotomy, and any additional employment information. Experience documentation forms must be downloaded from the website at www.ascp.org/docforms. Forward this form to your employer(s) for verification of your experience. Completed Experience documentation forms along with a letter from your employer, on official letterhead, verifying authenticity must be submitted with your application. (Printed Experience documentation forms are available upon request.) Your application will not be processed without the Experience documentation form(s) and letter(s) of authenticity attached. Step 7: Contact Information/Mothers Maiden Name (Required) The Board of Certification will be mailing you time-sensitive documents; it is imperative that we are able to contact you at all times. Please indicate two individuals who are likely to know your current address and phone number at all times. Indicate your mothers maiden name in the space provided. Step 8: Review Application
2

Have you included the appropriate examination fee?

An application fee must be included with your application form. All fees must be submitted by check or money order in U.S. currency (DO NOT SEND CASH). Make checks payable to Board of Certification. The ASCP Board of Certification will not accept post-dated checks. Application fees are non-refundable. Your application will be returned to you if it is not accompanied by a fee. Purchase Orders or Vouchers will not be accepted for application fees. A check or money order must accompany the application form. Faxed applications will not be accepted. $135 Phlebotomy Technician

Mailing Addresses
Applications and application fees MUST be mailed using the UNITED STATES POSTAL SERVICE REGULAR MAIL ONLY. DO NOT send applications and fees by Fax, Federal Express, UPS, Express Mail, Certified or Registered Mail or any overnight courier service or any other express mail service. Applications and application fees using express mail service WILL NOT reach the BOC office. Application/Fee with documentation (UNITED STATES POSTAL SERVICE REGULAR MAIL ONLY): Board of Certification 3335 Eagle Way Chicago, IL 60678-1033 You may also apply online with a Credit Card. For Multiple Application Fees: If multiple applications are being sent with one check, DO NOT use the above address. Contact www.ascp.org/bocfeedback for mailing instructions. General Correspondence and Transcripts WITHOUT checks or money order-: ASCP Board of Certification 33 W. Monroe Street, Suite 1600 Chicago, IL 60603 Should you have questions, or if any of the information on the completed application form changes, please contact the ASCP Board of Certification office at 312-541-4999, or online at www.ascp.org/bocfeedback.

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APPLICATION for ASCP Board of Certification for Phlebotomy LBX 3335 Technician (PBT)
Application fees are non-refundable. Be sure you meet the eligibility requirements as stated and are able to provide the appropriate documentation before submitting your application form and fee. Step 1: Indicate Examination Category and Route Exam Category P B T Route

Mailing Addresses
Applications and application fees MUST be mailed using the UNITED STATES POSTAL SERVICE REGULAR MAIL ONLY. DO NOT send applications and fees by Fax, Federal Express, UPS, Express Mail, Certified or Registered Mail or any overnight courier service or any other express mail service. Applications and application fees using express mail service WILL NOT reach the BOC office. Application/Fee with documentation (UNITED STATES POSTAL SERVICE REGULAR MAIL ONLY): Board of Certification, 3335 Eagle Way, Chicago, IL 60678-1033 You may also apply online with a Credit Card. For Multiple Application Fees: If multiple applications are being sent with one check, DO NOT use the above address. Contact www.ascp.org/bocfeedback for mailing instructions. General Correspondence and Transcripts WITHOUT checks or money order: ASCP Board of Certification, 33 W. Monroe Street, Suite 1600, Chicago, IL 60603

Have you applied previously for this exam category? If YES, indicate: Mo/Yr Check/Money Order Amount Submitted $

(Required for identification purposes) Step 2: Personal Information (Fill out completely. Print plainly in black ink.) Birth Date Required

(mm/dd/yyyy) Middle Initial

Last 4 digits of U.S. Social Security Number Mr. Mrs. Miss Ms.

Daytime Phone Number (Required) Home Office

Last Name (as it appears on your identification)

First Name (as it appears on your identification)

Maiden Name (if applicable)

Email Address

Home Address

City

State

Zip Code

Country (if foreign)

Gender (Required) F Female

M Male

Ethnicity (See Instructions)

Step 3: Prior ASCP Certification (if applicable) Category Certification Number

Step 4: Phlebotomy Training Program Information (Skip this step if you are applying based on work experience.) NAACLS APPROVED (Route 1) School Code Two-part Formal Structured Program (Route 2) Other Allied Health Program (Route 4)

CA Dept. of Public Health Approved Program (Route 1) Date Program Began / / Date Program Ends or Ended (Not graduation date) / /

Name of Institution Street Address Program Director Signature (CA Programs Required)

Name of Program Director City

Telephone Number with Area Code State Zip

I attest that the applicant named above has completed within the last five years his/her CA Dept. of Health Services approved phlebotomy program. Program Director Signature Date Signed NOTE: Applicants from CA approved training programs must submit a training documentation form and letter of authenticity with this application form. CONTINUED ON PAGE 4
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Step 5: Academic Education (Required) Indicate month and year your education was completed (X). HS Degree/GED Name of Institution Attended

/
City and State or Country Degree Completed & Date of Degree

Applicants with foreign education: A transcript evaluation form from one of the agencies listed in the Procedures Booklet is required. Step 6: Employment Information (if applicable)

Present Employer

Job Title

Date Started

Address

City and State

Zip Code

Immediate Supervisors Name

Total Employment Experience in Phlebotomy Years Months Only experience in the U.S., Canada or an accredited laboratory [laboratory accredited by a CMS approved accreditation organization (i.e., AABB, CAP, COLA, DNV, The Joint Commission, etc.)] is acceptable. Briefly describe your duties

List additional positions held and dates of employment, giving name of laboratory, supervisor, city, state and telephone number

Step 7: Contact Information and Mothers Maiden Name (Required) List below two individuals who are likely to know your address at all times. Mothers Maiden Name

Name

Address

City and State

Zip Code

Telephone Number

Name

Address

City and State

Zip Code

Telephone Number

Step 8: Pledge (Required)

By submitting and signing this application, I acknowledge that this application will be reviewed and processed, and that the examination will be conducted in accordance with the rules and policies adopted by the Board of Certification. I agree to hold harmless the members, examiners, officers and agents of the Board of Certification from any and all actions that they may take, or refrain from taking, pursuant to such rules and policies. I certify that all information contained in this application, as well as any information that I submit in support of this application, is true and correct to the best of my knowledge and belief. I authorize representatives of the Board of Certification to verify the accuracy of any information contained in, or supplied in support of, this application from any person or persons having knowledge of such information. I recognize that admission to take the certification examination, and certification if granted, are based on the correctness of the information contained in, and supplied in support of, this application. I further recognize that admission to take the certification examination and any certification I may have or be granted, may be revoked at any time, and that I may be barred from admission to take further certification examinations, if it is established that the information contained in, or supplied in support of, this application is inaccurate in any material respect, if I engage in any inappropriate conduct during the examination (such as giving or obtaining unauthorized information or aid), or if it is determined that I have misrepresented or misused any certification I may have or be granted. I understand that this examination and all test questions are the exclusive property of the Board of Certification and are protected by copyright law. Because of the confidential and proprietary nature of these copyright materials, I agree not to retain, copy, disclose or reveal any part of these examination materials, unless previously authorized in writing by the Board of Certification. I understand that the certificate of certification is time-limited for three years and that it must be renewed every three years for my certification to remain valid. I understand and agree that I will not use ASCP certification designation or CM (in superscript) after my name if I do not maintain a valid certification.

Applicants Signature (Required)

Date

REVISED 7/12