Certified Medical Laboratory Assistant Certifications - Certified Medical Laboratory Assistant Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone*Email* School Attended* Graduation Date* MM slash DD slash YYYY Employer,* Employer's Mailing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Employer's Phone*Emergency Contact Name* First Last Emergency Contact Phone*Emergency Contact Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Professional Phlebotomy Certification (CPT) Exam* Price: Payment Terms* I agree to the terms below. PLEASE NOTE: Payment is to be made via Debit Card or Credit Card through PayPal; once you submit your application, you will be directed to that site. If you do not have a PayPal account and/or prefer to pay by check, you are welcome to do so. Simply submit your application and contact our office to arrange payment. When directed to the PayPal site (upon application submission) you may simply close the page.CAPTCHA
