Application Form
American Board of Medical Laboratory Immunology Application Form Instructions
· Before completing the application form, carefully review ABMLI eligibility to be certain you meet the stated requirements.
· To prevent delays in processing, fill in all information on the application form. Submit the following:
1. Notarized ABMLI application form.
2. Official graduate transcripts or transcript evaluation. Transcripts must be mailed directly to the ABMLI from the issuing institution.
3. Letters of reference.
4. Application fee.
The application deadline is February 1, 2007. Applications and all supporting documentation must be received at the address below no later than February 1, 2007. The examination will be administered in the spring of that year on site at the General Meeting of the American Society for Microbiology.
Send application materials to:
ABMLI
1752 N Street, NW
Washington, DC 20036-2904
Fee Policies
· ASM members will be eligible for discounts on all examination and re-examination fees. The fee for ASM members is $600 in U.S. currency; the fee for non-members is $657. Acceptable forms of payment are a check, made payable to the American Board of Medical Laboratory Immunology, a money order, or a credit card payment (to pay by credit card, please use the attached form).
· All incomplete and/or ineligible applications will be returned with a partial refund; there is a 25% administration fee.
· If an applicant is found eligible for examination, he/she must initiate the examination process within two examination administrations of the date of approval. No refund will be made to a candidate found eligible for examination who fails to initiate the examination process within that time frame.
· Candidates have up to three opportunities to take the exam within four examination cycles. Any candidate who does not successfully complete the exam within three tries, or who fails to take the exam on two consecutive examination dates, must submit a new application and full fee before re-examining.
· The reexamination fee is $400 for ASM members and $457 for non-members.
· Once an examination has been scheduled, no refund will be issued upon cancellation.
American Board of
Medical Laboratory Immunology
/ 1752 N Street, NWWashington, DC 20036-2904
(202) 942-9281 telephone
(202) 942-9353 fax
APPLICATION FORM
Revised June 2006
/ IMPORTANT: Type or print clearly and complete all sections.I. Examination Category: Check the examination plan below under which you are applying.
1 Plan A 1 Plan B 1 Plan C 1 ABMM DiplomateII. Biographical Data: Notify the ABMLI office immediately of any changes in your contact information.
Name (First, M.I., Last): /Mailing address: / Daytime telephone number:
E-mail address:
Fax number:
U.S. Social Security number:
Gender: 1 Male 1 Female / ASM Member number (if applicable):
Name as you would like it to appear on your certificate:
III. References: Applicants must submit three letters of reference, one from their immediate supervisor and two from persons not related to them who have definite knowledge of their training, experience, and qualifications.
Supervisor:
Colleague:
Colleague:
VI. Academic Education: All educational requirements must be met through institutions accredited by a regulatory agency recognized by the U.S. Department of Education. Official graduate transcripts must be mailed directly to the ABMLI from the issuing institution.
Institution(undergraduate and graduate) / City, state / Major subject / Degree
Type / Date conferred
Postdoctoral courses completed relevant to Medical Laboratory Immunology
Course description / Credits / Year takenV. Training and Experience Record: Postdoctoral Training in Medical Laboratory Immunology
Institution: / Dates attended ___ month ___ year to ___ month ___ yearLocation: / 1 Full-time 1 Part-time
Program director: Telephone number: / Program completed? 1 Yes 1 No
Program accredited by the American College of Microbiology (CPEP)? 1 Yes 1 No
If yes, skip to Postdoctoral Experience section. If not, describe below your duties and percentages of time devoted to each activity below.
Postdoctoral Experience: Start with your present position and work back. Additional sheets may be added if required.
Employment dates: ______month ______year to ______month ______yearSize of institution (if a hospital, list the number of beds and number of supervisees): / Immediate supervisor:
Title: / Employer’s name and address:
Describe your duties, giving percentages of time devoted to the following areas:
___% Administrative
___% Administrative:
___% Diagnostic and clinical
___% Research
___% Teaching
VI. Training and Experience Record (Cont’d): Postdoctoral Experience in Medical Laboratory Immunology
Size of institution (if a hospital, list the number of beds and number of supervisees): / Immediate supervisor:
Title: / Employer’s name and address:
Describe your duties, giving percentages of time devoted to the following areas:
___% Administrative
___% Diagnostic and Clinical
___% Research
___% Teaching
VII. Affidavit
State of ______, County of ______
I, ______, do solemnly swear (affirm) that I am the applicant named in this application; that I have made or read the contents hereof; that I have read and understood the contents of the American Board of Medical Laboratory Immunology Application; and to the best of my knowledge and belief the foregoing statement and answers are true in substance and effect and are made in good faith.
______
Signature of Applicant
Subscribed and sworn to me this ______day of ______, ______
month year
______
Signature of Notary Public
Notary Public in the State of ______My Commission expires ______, ____ year
Payment must accompany application and may be made by check payable to the American Board of Medical Laboratory Immunology or by credit card.
To pay by credit card, please complete the section below. Visa, MasterCard, and American Express are accepted.
Visa Mastercard
AmEx
Eurocard / Credit card number / Expiration
MasterCard / date
American Express / Month / Year
Name as it appears on credit card
Today’s date / Signature______
Month Day Year
If you would like a receipt sent to you, please check this box:
How would you like your receipt sent to you? By email at: ______ By fax at: ______(ATTN:______)
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