National Certification Registration Form: American Phlebotomy Association Date: ___________ Name Address: City, State, Zip Date of Birth Phone Last 4 of Social Security# Work Email On Line: APA APA Certifications Cost Certified Phlebotomy Technician (CPT) Certified EKG (CET) Certified Medical Laboratory Assistant (CMLA)* Certified Patient Care Technician Certified Clinical Research Assistant (CCRA)* Registered Medical Assistant (RMA) Home Time Cell Classroom Location APAOnline CPT $105.00 $105.00 CMLA $150.00 CPCT 1.5 Hour Exam 100 Questions Hours 100 questions 2 Hour Exam 125 Questions 2.0 Hours 200 questions CCRA $150.00 2 Hour Exam 100 Questions APAOnline RMA $150.00 200 Questions 2 Hour Exam APA Online Certification Sample APAOnline *The Following Exams Include Phlebotomy National Certifications: *Certified Medical Laboratory Assistant *Certified Clinical Research Assistant *Registered Medical Assistant Make Checks Payable To: “APA”. 2500 N. Rolling Road Suite 202 Windsor Mill, MD. 21244 Signature________________________________________________________________ Date________ □ Visa □ Master □AMEX Credit Card #: ____________________________________ Exp. Date__________ CV Code (last three digits on back of card) ______________________________ I hereby authorize the charge of $______________ to my account as listed above. Card holder’s Signature_______________________________________Print ____________________________ 848 N. Rainbow Blvd. Las Vegas NV 89107|1.866.935.3339 | Fax: 1.866.469.3688 | www.apa2.com National Certification Registration Form: American Phlebotomy Association **Please Call If Interested In Certified Healthcare Instructor 848 N. Rainbow Blvd. Las Vegas NV 89107|1.866.935.3339 | Fax: 1.866.469.3688 | www.apa2.com