|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 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 $175.00 by
electronic check or credit card payable to the NMTCB.
I understand that
any request to withdraw my application will be subject to the approval
of the NMTCB. I also understand that if I fail to keep an appointment
to sit for the examination, without approval from the NMTCB, I will be
required to resubmit the entire application and applicable fee at the
time of reapplication. 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.
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 acknowledge that the NMTCB will not release my score results or examination status to the general public. In an effort to assist program directors and medical directors to better evaluate the effectiveness of nuclear medicine technology programs, by signing below, I acknowledge that my examination results will be sent to such program officials. The NMTCB will verify, upon request from employer and state licensing agencies, whether or not an individual has an active certificate.
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 understands 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.
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 $175.00 payment to:
3558 Habersham at Northlake
Tucker, GA 30084