Application Form

American Board of Medical Microbiology

Rev. 06/22/07

APPLICATION FORM INSTRUCTIONS

  • Before completing the application form, carefully review the ABMM eligibility information to be certain you meet the stated requirements.
  • To prevent delays in processing, fill in all information on the application form. Be sure to put the name of your current employer. Submit the following:

1. Notarized ABMM application form.

  1. Official graduate transcripts or transcript evaluation (must be mailed directly to the ABMM by the issuing institution).
  1. Notarized copy of your marriage license or name change certificate (only if the name on your transcript does not match the name on your application form and reference letters).
  1. Reference letters documenting the minimum work experience requirement. Letters may be mailed separately or with the application; they must be originals.
  1. Application fee.

The application deadline is February 1. Applications and all supporting documentation must be received at the address below no later than February 1.

The examination is administered each spring on site at the General Meeting of the American Society for Microbiology.

Send application materials to:

ABMM

1752 N Street, NW

Washington, DC20036-2904

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 Microbiology, a money order, or a credit card payment (to pay by credit card, please use the attached form).
  • 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 twoexamination cycles of application approval. No refund will be made to a candidate found eligible for examination who fails to initiate the examination process.
  • Once an examination has been scheduled, no refund will be issued if the candidate cancels his/her sitting. No exceptions will be made.
  • Candidates have five years from their approval date in which to successfully complete the examination process; subsequent reexamination requires a new application and fee.
  • The reexamination fee is $400 for ASM members and $457 for non-members.

American Board of

Medical Microbiology

/ 1752 N Street, NW
Washington, DC 20036-2904
(202) 942-9281 telephone
(202) 942-9353 fax

APPLICATION FORM
RevisedJune 2007
/ IMPORTANT: Type or print clearly and complete all sections. Do not staple.

I. Examination Category: Check the plan under which you are applying.

Plan I:Applicants must possess an earned doctorate and complete a minimum of 3 years of experience.
Plan II:Applications must possess an earned doctorate and complete 2 years of postgraduate training in a postdoctoral training program approved by the American College of Microbiology’s Committee on Postgraduate Educational Programs (CPEP).
  1. Biographical Data: Notify the ABMM 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:
ASM member number (if applicable):
Gender:  Male  Female / Current employer:
Print your name here as you wish it to appear on your certificate:
How were you referred to the ABMM?
Who is paying your application fee? ڤ I am ٱ My employer is

III.References:Two letters of reference must be submitted, one from an immediate supervisor andone from a person (not related to you) who has definite knowledge of your training and experience in medical microbiology. A minimum of two letters is required, unless you have completed a CPEP-approved training program, in which case one letter from the program director will be sufficient.

Supervisor / Institution / City / State
Colleague / Institution / City / State
IV.Graduate Education: Official graduate transcripts must be mailed directly from the issuing institution to the ABMM.
Institution / Location / Major subject / Degree
Type / Date conferred

V. Postdoctoral Training: Participation in a formal training program.

Institution / Location / Program director / Telephone
Program accredited by the AmericanCollege of Microbiology (CPEP)? YesNo Program completed?YesNo
Dates attended (MM/YY to MM/YY): / to / Full-timePart-time
If you have not yet completed the program, expected date of completion (MM/DD/YY): / /

If the postdoctoral training program is accredited by the College, skip to section VI, Postdoctoral Experience. If not, describe your duties and percentage of time devoted to each activity below.

%

Responsibilities and skills in the clinical laboratory

%

Interaction and consultation with clinicians

%

Management and administrative skills

  1. Postdoctoral Experience:Start with your present position and work back. Additional sheets may be added if required.

Employment dates (MM/YY to MM/YY) / Title / Institution / Location
Size of institution* / Immediate supervisor / Telephone
* If hospital, please list the number of beds and number of people supervised.

Describe your duties, giving percentages of time devoted to the following areas:

%

Responsibilities and skills in the clinical laboratory

%

Interaction and consultation with clinicians

%

Management and administrative skills

VI. Postdoctoral Experience (Continued):

Employment dates (MM/YY to MM/YY) / Title / Institution / Location
Size of institution* / Immediate supervisor / Telephone
* If hospital, please list the number of beds and number of people supervised.

Describe your duties, giving percentages of time devoted to the following areas:

%

Responsibilities and skills in the clinical laboratory

%

Interaction and consultation with clinicians

%

Management and administrative skills

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 Microbiology 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 ______,______

Payment must accompany application and may be made by check payable to American Board of Medical Microbiology or by credit card.

To pay by credit card, please complete the section below. Visa, Mastercard, and American Express are accepted.

 Visa / Credit card number: / Expiration
 MasterCard / date:
 American Express / Month / Year
Name as it appears on credit card:
Today’sDate: / 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: ______