MEDICAL TECHNICIAN SKILLS EVALUATION - Page 2
MEDICAL TECHNICIAN SKILLS EVALUATION - Page 2
Personal Information
Name
*
First
Last
Title / Specialty
*
Email
*
Phone
-
(###)
-
###
####
ASCP Technician
MLT #
Histologic Technicians #
Phlebotomy #
ASCP Technologist
MLT #
Blood Banking #
Chemistry #
Cytotechnologist #
Hematology #
Histo Technologist #
Immunolgy #
Microbiology #
ASCP Specialist
Hemapheresis #
Blood Banking #
Hematology #
Immunology #
Microbiology #
Cytotechnology #
Virology #
Laboratory Safety #
ASCP Diplomats
Laboratory Management #
NCA #
HEW #
AMT #
Please check all which apply:
BLS
ACLS
CPR
State Licensed:
State:
Expiration:
State:
Expiration:
State:
Expiration:
State:
Expiration:
