PET Exam Application
|CONTACT INFORMATION||All examination candidates must complete this section|
| 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.
|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.
|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.
|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.
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:
Signature of Applicant
(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:
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