National Certification Registration Form: American Phlebotomy Association Date: ___________ Name Address: City, State, Zip Date of Birth Phone Last 4 of Social Security# Work Home Cell Email On Line: APA APA Certifications Cost Time Classroom Location APACertification Sample Certified Phlebotomy Technician (CPT) Certified Medical Laboratory Assistant (CMLA)* Certified Clinical Research Assistant (CCRA)* CPT $105.00 CMLA $150.00 1.5 Hour Exam 100 Questions 2 Hour Exam 150 Questions CCRA $150.00 2 Hour Exam 100 Questions APAOnline Registered Medical Assistant (RMA) RMA $150.00 200 Questions 2 Hour Exam APA Online Online APAOnline *The Following Exams Include Phlebotomy National Certifications: *Certified Medical Laboratory Assistant *Certified Clinical Research Assistant *Registered Medical Assistant Make Checks Payable To: “APA”. 90 Painters Mill Road (Suite 120)…Owings Mills, MD. 21117 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. 90 Painters Mill RD. (Ste 120) Owings Mills, MD. 21117 |1.866.935.3339 | Fax: 1.866.469.3688 | www.apa2.com National Certification Registration Form: American Phlebotomy Association Card holder’s Signature_______________________________________ Print ____________________________ **Please Call If Interested In Certified Healthcare Instructor 90 Painters Mill RD. (Ste 120) Owings Mills, MD. 21117 |1.866.935.3339 | Fax: 1.866.469.3688 | www.apa2.com