Program Graduate Application

Program Graduate 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. This page is encrypted before being sent.
  5. You will be asked for the six-digit school code. These can be found by clicking here.
  6. The application fee is $175.00 and payment information will be taken after you submit this form.
CONTACT INFORMATION
Mr. Ms. Mrs. Dr.  
FIRST NAME
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MIDDLE INITIAL (one letter only)
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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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PERSONAL EMAIL ADDRESS
Use personal email not school email address.
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HAVE YOU PREVIOUSLY APPLIED FOR THE NMTCB 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
The NMTCB Certificant directory is available on our website to certified individuals. Upon certification, will you want your home phone number to be included?
YES    NO
I UNDERSTAND THAT I WILL RECEIVE A LIST OF AVAILABLE TEST SITES WITH MY AUTHORIZATION LETTER
I ATTEND/ATTENDED THIS NMTCB APPROVED SCHOOL
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THE SCHOOL CODE IS:
View list of school codes.
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I HAVE GRADUATED/WILL GRADUATE ON:
Enter Date
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For this program, did you obtain a:
Certificate
Associates Degree
Baccalaureate Degree
Master's Degree
Besides the certificate or degree you received/will receive from the Nuclear Medicine Technology program, do you hold another degree?
Yes No
If so, what is that degree?
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...
NMTCB reserves the right to require and the applicant agrees to undergo, at the applicant’s expense, a national criminal background check through a source and under conditions determined by the NMTCB. NMTCB shall provide the applicant with a reasonable notice and period of time to complete this background check and the applicant agrees to cooperate in this regard.

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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 $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:

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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 $175.00 payment to:

NMTCB
3558 Habersham at Northlake
Building I
Tucker, GA 30084