PET Exam Application

PET Exam Application





INSTRUCTIONS:
  1. Read instructions first.
  2. The NMTCB accepts online payments by MasterCard® and Visa® credit card only.
  3. All examination candidates must complete all sections of this application.
  4. The application fee is $225.00 and payment information will be taken after you submit this form.
CONTACT INFORMATION All examination candidates must complete this section
Mr. Ms. Mrs. Dr.
FIRST NAME
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MIDDLE NAME
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LAST NAME
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ADDRESS LINE 1
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ADDRESS LINE 2
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CITY
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STATE/PROVINCE
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ZIP CODE
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DAYTIME TELEPHONE
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EVENING TELEPHONE
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SOCIAL SECURITY NUMBER
if Canadian, enter your Social Insurance Number
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DATE OF BIRTH
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EMAIL ADDRESS
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SNMMI MEMBER NUMBER
NMTCB will forward certificate for 24 hours CE credit
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HAVE YOU PREVIOUSLY APPLIED FOR THE PET EXAM?
YES   NO
Are you interested in receiving mail from professional organizations?
YES   NO
Are you interested in receiving mail from commercial organizations?
YES    NO
CERTIFICATION REQUIREMENT
Check the appropriate box(es) indicating the organization(s) with which you are CURRENTLY certified/registered in nuclear medicine technology, radiography or radiation therapy.
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NMCTB Only

ARRT Only

NMTCB & ARRT

CAMRT Only

NMTCB & CAMRT

ARRT & CAMRT

CERTIFICATION NUMBERS
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IF YOU DO NOT HOLD ACTIVE CERTIFICATION IN NUCLEAR MEDICINE, YOU MUST SUBMIT DOCUMENTATION OF AT LEAST 15 HOURS OF DIDACTIC COURSEWORK IN NUCLEAR MEDICINE INSTRUMENTATION, 15 HOURS OF DIDACTIC COURSEWORK IN RADIATION SAFETY AND 15 HOURS OF DIDACTIC COURSEWORK IN RADIOPHARMACY.
You must fax your documentation to the NMTCB Office at (404) 315-6502. For a copy of a form to use for submitting documentation, click on this link.
CLINICAL EXPERIENCE (ALL APPLICANTS)  
List clinical PET experience in this section in descending order, beginning with current employer. 700 hours of clinical experience as a certified/registered nuclear medicine technologist on a dedicated PET scanner or PET/CT scanner is required.
For radiographers or radiation therapists, the requirement is 700 hours of documented clinical experience performing all aspects of PET imaging including radiopharmaceutical handling, injection (if permitted by state and/or institutional regulations) and imaging. Imaging may be performed on a PET and/or a PET/CT scanner. Supervision must be performed by a nuclear medicine physician or radiologist AND direct supervision must be performed by a certified NMTCB, ARRT(N) or CAMRT(RTNM) technologist.
Experience #1  
SUPERVISING PHYSICIAN
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PHYSICIAN BOARD CERTIFICATION
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PHYSICIAN OFFICE TELEPHONE
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TECHNICAL SUPERVISOR
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TECHNICAL SUPERVISOR TELEPHONE
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DIRECTOR OF PERSONNEL
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PERSONNEL OFFICE PHONE
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INSTITUTION/COMPANY NAME & MAILING ADDRESS
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DATES EMPLOYED
FROM 
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TO      
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Experience #2  
SUPERVISING PHYSICIAN
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PHYSICIAN BOARD CERTIFICATION
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PHYSICIAN OFFICE TELEPHONE
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TECHNICAL SUPERVISOR
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TECHNICAL SUPERVISOR TELEPHONE
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DIRECTOR OF PERSONNEL
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PERSONNEL OFFICE PHONE
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INSTITUTION/COMPANY NAME & MAILING ADDRESS
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DATES EMPLOYED
FROM 
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TO      
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Experience #3  
SUPERVISING PHYSICIAN
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PHYSICIAN BOARD CERTIFICATION
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PHYSICIAN OFFICE TELEPHONE
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TECHNICAL SUPERVISOR
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TECHNICAL SUPERVISOR TELEPHONE
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DIRECTOR OF PERSONNEL
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PERSONNEL OFFICE PHONE
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INSTITUTION/COMPANY NAME & MAILING ADDRESS
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DATES EMPLOYED
FROM 
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TO      
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Ethics Questions (Be advised that providing false or misleading information may result in permanent disqualification for any or all NMTCB examinations.)
HAVE YOU EVER...
a) ...been charged with or convicted of a misdemeanor (other than a minor traffic offense) or felony or general court martial in military service, and/or are any such charges currently pending against you?

If you answered 'Yes' to the above question, you must provide an explanation:
yes or no
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b)...had any professional license, registration, or certification application denied, or any issued license, registration, or certification revoked, suspended, placed on probation, or subject to any type of discipline by a regulatory authority or certification board?

If you answered 'Yes' to the above question, you must provide an explanation:
yes or no
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c) ...been found by any court or administrative body, including but not limited to employers, to have committed negligence (simple or willful), malpractice, recklessness, or engaged in misconduct in the practice of any profession?

If you answered 'Yes' to the above question, you must provide an explanation:
yes or no
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d) ...been terminated from an employment position involving the use of NMTCB credentials and where the conduct leading to such termination has involved: child or elder abuse, sexual abuse, substance abuse, job-related crimes, violent crimes against persons?

If you answered 'Yes' to the above question, you must provide an explanation:
yes or no
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If you answered yes to any question above, you MUST provide an explanation. Felony convictions require court documentation.
ATTESTATION AND STATEMENT OF APPLICANT

Read each of the following statements... Please initial below to indicate you have read and understand each of the statements...
I understand that the NMTCB reserves the right to require a national criminal background check, at my expense, through a source and under conditions determined by the NMTCB. The NMTCB shall provide me with a reasonable notice and period of time to complete this background check. I hereby grant the NMTCB permission to perform a national criminal background should it be deemed appropriate.

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I have read, am in compliance with, and agree to continue compliance with all of the NMTCB’s rules and regulations, as may be revised from time to time by NMTCB, including, but not limited to, the NMTCB eligibility requirements, disciplinary and appeal procedures, certification, annual renewal, fees, ethics standards, and continuing education policy.

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I understand that any intentional or unintentional failure to provide true and complete responses to this application may result in denial of an application for certification or disciplinary action by the NMTCB.

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I authorize the NMTCB to confirm the information contained in this application and allow the NMTCB to request information related to my education, employment, relevant personal history, and professional license, registration, or certification.

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I hereby make application to the Nuclear Medicine Technology Certification Board, Inc. (NMTCB) for examination and certification in accordance with and subject to NMTCB rules and regulations adopted from time to time. I understand and agree to be bound by all rules and regulations adopted by the NMTCB.

I am enclosing the nonrefundable fee of $225.00 by credit card payable to the NMTCB. I understand that the application fee is nonrefundable and that, once my application is approved, I am required to make an appointment and appear for the examination within 6 calendar months of the date that appears on my eligibility approval letter. I also understand that if I fail to make an appointment during the eligibility period, I may extend the eligibility period by an additional six calendar months one time for a fee of $50.00 USD.

I understand that I must contact the NMTCB office immediately if circumstances make it impossible for me to appear on the date scheduled. I also understand that candidates who fail to appear on the date scheduled or fail to change their scheduled appointment more than 96 hours in advance, may reschedule within the same eligibility period for a fee of $100.00 USD and candidates who fail to appear on the date scheduled and wish to extend the eligibility period by an additional six calendar months one time may do so for a fee of $150.00 USD.

I understand that if I fail to sit for the exam within one calendar year of eligibility approval, I will be required submit the full application fee in order to reactivate the application and be considered eligible.

I hereby submit this application and supporting documents and attest to the authenticity and accuracy of the application and all information contained herein. I also understand that, in the event that any information contained in this application or supporting documents submitted on my behalf, is determined by the NMTCB to be false or misleading, this application may be denied, entrance to the examination may be refused, examination score withheld or invalidated, and any other remedy available to the NMTCB, including adverse action against any already issued NMTCB certification. NMTCB also reserves the right in its sole discretion to turn such information over to state or federal administrative or criminal authorities.

I agree to abide by all NMTCB policies and procedures related to the application and certification process. I hereby recognize the NMTCB owned intellectual property rights including the examination and its processes and agree to maintain the confidentiality of these copyrighted materials. I further understand that giving aid to or receiving aid from any third parties in taking this examination or advising any third parties of any of the questions or answers orally, in writing or through any media before, during or after the examination or other misuse of the NMTCB materials protected under intellectual property laws will be sufficient cause for the NMTCB to deny my application, withhold or invalidate my examination score, disqualify me from reexamination, impose an adverse action against an already issued NMTCB certificate, and any other remedy available to the NMTCB, including civil and criminal remedies under applicable laws.

I declare that I have examined this application and, that to the best of my knowledge and belief, the statements contained herein are true, correct and complete. I authorize representatives of the NMTCB to verify the accuracy of any information contained in this application from any persons having knowledge of such information. It is my intent that this acknowledgment and authorization act as a release to all entities, including educational institutions, professional organizations, and/or employers, regarding the disclosure directly to NMTCB of all relevant information for purposes of processing my application.

I understand that the application, all information contained therein and any supporting documents submitted on behalf of the applicant are the property of the NMTCB and may be used for any purpose within the mission of the NMTCB.

I agree and promise to hold the NMTCB and its members, agents, officers and committee members harmless from any damages or loss, monetary or otherwise, incurred by reason of any action taken by NMTCB in this application process including, but not limited to, the refusal to issue or recognize an examination score, refusal to issue NMTCB certification, or removal of NMTCB certification.

I certify that I am the candidate whose signature appears below and agree to supply any other documentation designed to ensure my identification and maintain the integrity of the application NMTCB process.


Be advised that your name entered on this form constitutes your agreement with the statements in this application:

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(Enter Full Name)

*If you do not wish to submit your payment electronically, please complete and print this form. Click here for the pdf version. Mail this application form, any supporting documentation and your $225.00 payment to:

NMTCB
3558 Habersham at Northlake
Building I
Tucker, GA 30084