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Print this form and fax or mail:
Fax to: (505) 797-3822
Mail to: 5150 San Francisco RD NE, Albuquerque, NM 87109
Last Name: ___________________________________
First Name: ___________________________________
Middle Initial: ___________________________________
Street Address: ___________________________________
City: ___________________________________
State: ___________________________________
Zip Code: ___________________________________
Telephone: ___________________________________
E-mail: ___________________________________
Profession: ___ MT Years Experience: ______ ___ MLT Years Experience: ______ ___ HISTO Years Experience: ______ ___ CYTO Years Experience: ______ ___ PHLEB Years Experience: ______ ___ LAB ASSISTANT Years Experience: ______
Instructions: Complete only those items that apply to your profession.
SPECIALTIES: [Please check all areas you are qualified and experienced to work.]
___ GENERAL ___ BLOOD BANK ___ CHEM ___ MICRO ___ X-RAY
OTHER: _______________________ OTHER: _______________________
OTHER: _______________________ OTHER: _______________________
PROFESSIONAL LICENSURE:
License #: ____________ State: ____ License #: ____________ State: ____
License #: ____________ State: ____ License #: ____________ State: ____
CERTIFICATIONS:
___ ASCP ___ NCA ___ AMT ___ HEW ___ CT ___ HT
Other: _______________________ Other: _______________________
Other: _______________________ Other: _______________________
CHICKEN POX STATEMENT:
o Yes, I have had chicken pox. o No, I have not had chicken pox.
Initial: _____ Date: __________
FACILITY/SPECIALTY PREFERENCE:
1st Choice: ____________________________ 2nd Choice: ____________________________ 3rd Choice: ____________________________
Signature: ___________________________ Date: __________
Phone / Email: ___________________________
