BAHTC Registration Form - American Phlebotomy Association

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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
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