Home Study Certification Application/Registration Form A and B

NHA Home Study Certification Program

Application/Registration Form A

(1) Print and Complete Form A, which must be completed by you the applicant

(2) Print and complete Form B, which is completed by your Sponsor/Employer

(3) Fax Form A and B with payment complete to 973-644-4797 or

Mail Form A and B back to:

NHA - National Headquarters

ATTENTION: Victoria Marmol

7 Ridgedale Ave., Suite 203

Cedar Knolls, NJ 07927

(4) You can also download the Application/Registration Form A & Form B for Home Study Certification Program as one file in PDF format:

NHA Home Study Certification Application Form

(Employer must complete and sign Employer Sponsorship form B. Click here!)

Name: _________________________________________________________

Address: _______________________________________________________

City/State: ______________________________________________________

Zip Code: _________

Telephone (day): _____________________ (evening): ______________________

E-mail Address: _____________________@___________________________

Social Security #:____________-_______-_____________

Certification(s) Applied For:

____________________________________________

Cost Of Home Study Certification:

1. Clinical Medical Assistant Certification: $169.00 *

2. Patient Care Associate Certification: $169.00 *

3. Nurse Technician Certification: $169.00 *

4. Patient Care Technician Certification: $169.00 *

5. Phlebotomy Technician Certification: $129.00

6. EKG Technician Certification: $129.00

7. Billing and Coding Specialist Certification: $129.00

8. Medical Administrative Assistant Certification: $129.00

9. Pharmacy Technician Certification: $129.00

10. Medical Laboratory Assistant Certification: $129.00

* Also includes certification in phlebotomy and EKG!

PAYMENT

Payment Options and Refund Policy:

1. Check or money order payable to NHA in the correct amount per certification.

Check #_______________________ OR

Money Order #_____________________

Amount Paid: $_____________________

2. To pay by Credit Card please indicate which card and print card number below.

Visa

MasterCard

Discover

American Express

Allow 2 weeks for information on approval

Name of Card Holder________________________________________________________

CC#______________________________________ Exp. Date___/___/_____

Signature______________________________________ Date___/___/_____

(For credit authorization)

I, _______________________________, state that all information submitted

on forms A and B is true. If any false information has been submitted, NHA may

reject or void my certification.

Signed: _________________________________________ Date___/___/_____

** REFUND POLICY

IF APPLICATION IS NOT ACCEPTED A FULL REFUND WILL BE ISSUED LESS A REGISTRATION FEE OF: $15.00.

PRINT FORM A & B AND SEND PAYMENT

Print and send completed Registration Forms A and B with payment to:

NHA - National Healthcareer Association

ATTENTION: Victoria Marmol

7 Ridgedale Ave., Suite 203

Cedar Knolls, NJ 07927

Credit card payments can be faxed to: 973-644-4797

ANY QUESTIONS PLEASE CALL 1-800-499-9092

(Employer must complete and sign Employer Sponsorship Form B below!)

NHA Home Study Certification Program

Application/Registration Form B

Name of Employer: _______________________________________________

Address: _______________________________________________________

City/State: ____________________________________ Zip Code: _________

Telephone (Day): _____________________ (Eve): ______________________

Employer/Sponsor: _______________________________________________

Title: __________________________________________________________

Phone #: _______________________________________________________

Years of Experience in Certification Skill: _______________________________

Applying For Certification In:

Clinical Medical Assistant *

Patient Care Associate *

Nurse Technician *

Patient Care Technician *

Phlebotomy Technician *

EKG Technician

Billing and Coding Specialist

Medical Administrative Assistant

Pharmacy Technician

Medical Laboratory Assistant

*Please note: Phlebotomy experience is a MUST for certification in:

Phlebotomy, Clinical Medical Assistant, and Nurse/Patient Care Technician/Associate

Definition of Certification Skills

Phlebotomy Technician - phlebotomy, venipuncture skills, and fingersticks (at least 2 years.)

EKG Technician - Perform setup and run EKG (at least 2 years.)

Clinical Medical Assistant - phlebotomy and EKG skills as outlined above, basic patient care in ambulatory/clinical setting, including blood pressures, routine laboratory screening tests, specimen processing, and infection control (all at least 2 years.)

Nurse/Patient Care Technician/Associate - must be Nurses's Assistant, phlebotomy and EKG skills as outlined above (all for at least 2 years.)

Billing and Coding - must have at least 2 years experience as medical biller/coder.

Medical Administrative Assistant - must have at least 2 years experience as medical administrative assistant (front office.)

Pharmacy Technician - must have at least 2 years experience in a hospital or retail pharmacy.

Medical Laboratory Assistant - at least 2 years of experience in medical laboratory, including lab setup, operation of machinery and equipment, specimen processing, basic hematology and chemistry tests, urinalysis, and infection control.

1. Does applicant perform the required skills as defined for the certification

being applied for?

Yes

2. Has the applicant performed these skills for at least 2 years?

Yes

3. How long has applicant performed these skills? ____ Years ____ Months

To the best of my knowledge the applicant has the experience and background

to be considered for certification in his/her field of expertise by the NHA.

Sponsor/Contact Signature _______________________ Date _____/_____/______

Sponsor/Contact Print Full Name ________________________________________

(Employer must complete and sign Employer Sponsorship form B. Click here!)

PRINT FORM A & B AND SEND!

Print and send completed Registration Forms A and B with payment to NHA

ANY QUESTIONS PLEASE CALL 1-800-499-9092

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NHA is a member of the National Organization of Competency Assurance (N.O.C.A. Washington, DC.)

Approved by the Clinical Laboratory Personnel Committee, Monroe, LA.

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