<p> Application Form American Board of Medical Laboratory</p><p>Immunology Rev. 12/27/06 APPLICATION FORM INSTRUCTIONS</p><p> Before completing the application form, carefully review ABMLI eligibility to be certain you meet the stated requirements.  To prevent delays in processing, fill in all information on the application form. Submit the following:</p><p>1. Notarized ABMLI application form. 2. Official graduate transcripts or transcript evaluation (must be mailed directly to the ABMLI from the issuing institution). 3. Letters of reference (may be mailed separately or with the application; they must be originals). 4. Application fee.</p><p>The application deadline is February 1, 2007. Applications and all supporting documentation must be received at the address below no later than February 1, 2007. The examination will be administered in the spring of that year on site at the General Meeting of the American Society for Microbiology. </p><p>Send application materials to:</p><p>ABMLI 1752 N Street, NW Washington, DC 20036-2904</p><p>FEE POLICIES</p><p> ASM members will be eligible for discounts on all examination and re-examination fees. The fee for ASM members is $600 in U.S. currency; the fee for non-members is $657. Acceptable forms of payment are a check, made payable to the American Board of Medical Laboratory Immunology, a money order, or a credit card payment (to pay by credit card, please use the attached form).</p><p> All incomplete and/or ineligible applications will be returned with a partial refund; there is a 25% administration fee.</p><p> If an applicant is found eligible for examination, he/she must initiate the examination process within two examination administrations of the date of approval. No refund will be made to a candidate found eligible for examination who fails to initiate the examination process within that time frame.</p><p> Candidates have up to three opportunities to take the exam within four examination cycles. Any candidate who does not successfully complete the exam within three tries, or who fails to take the exam on two consecutive examination dates, must submit a new application and full fee before re-examining. </p><p> The reexamination fee is $400 for ASM members and $457 for non-members. </p><p> Once an examination has been scheduled, no refund will be issued upon cancellation. 1752 N Street, NW Washington, DC 20036- 2904 American Board of (202) 942-9281 telephone (202) 942-9353 fax Medical Laboratory Immunology [email protected] rg APPLICATION FORM IMPORTANT: Type or print clearly and complete all sections. Do not staple. Revised December 2006</p><p>I. EXAMINATION CATEGORY: Check the examination plan below under which you are applying.</p><p> Plan A  Plan B  Plan C  ABMM Diplomate</p><p>II. BIOGRAPHICAL DATA: Notify the ABMLI office immediately of any changes in your contact information. Name (First, M.I., Last):</p><p>Mailing address: Daytime telephone number: E-mail address: Fax number: U.S. Social Security number: Gender:  Male  Female ASM Member number (if applicable): Name as you would like it to appear on your certificate:</p><p>III. REFERENCES: Applicants must submit three letters of reference, one from their immediate supervisor and two from persons not related to them who have definite knowledge of their training, experience, and qualifications. Reference Institution, city, state Supervisor: Colleague: Colleague:</p><p>VI. ACADEMIC EDUCATION: All educational requirements must be met through institutions accredited by a regulatory agency recognized by the U.S. Department of Education. Official graduate transcripts must be mailed directly to the ABMLI from the issuing institution. Institution Degree City, state Major subject (undergraduate and graduate) Type Date conferred</p><p>POSTDOCTORAL COURSES COMPLETED RELEVANT TO MEDICAL LABORATORY IMMUNOLOGY Course description Credits Year taken V. TRAINING AND EXPERIENCE RECORD: Postdoctoral Training in Medical Laboratory Immunology Institution: Dates attended ___ month ___ year to ___ month ___ year Location:  Full-time  Part-time Program director: Telephone number: Program completed?  Yes  No</p><p>Program accredited by the American College of Microbiology (CPEP)?  Yes  No </p><p>If yes, skip to Postdoctoral Experience section. If not, describe below your duties and percentages of time devoted to each activity below.</p><p>POSTDOCTORAL EXPERIENCE: Start with your present position and work back. Additional sheets may be added if required. </p><p>Employment dates: ______month ______year to ______month ______year</p><p>Size of institution (if a hospital, list the number of beds and Immediate supervisor: number of supervisees):</p><p>Title: Employer’s name and address:</p><p>Describe your duties, giving percentages of time devoted to the following areas: ___% Administrative</p><p>___% Diagnostic and clinical</p><p>___% Research</p><p>___% Teaching VI. TRAINING AND EXPERIENCE RECORD (CONT’D): Postdoctoral Experience in Medical Laboratory Immunology</p><p>Employment dates: ______month ______year to ______month ______year</p><p>Size of institution (if a hospital, list the number of beds and Immediate supervisor: number of supervisees):</p><p>Title: Employer’s name and address:</p><p>Describe your duties, giving percentages of time devoted to the following areas: ___% Administrative</p><p>___% Diagnostic and Clinical</p><p>___% Research</p><p>___% Teaching</p><p>VII. AFFIDAVIT State of ______, County of ______</p><p>I, ______, do solemnly swear (affirm) that I am the applicant named in this application; that I have made or read the contents hereof; that I have read and understood the contents of the American Board of Medical Laboratory Immunology Application; and to the best of my knowledge and belief the foregoing statement and answers are true in substance and effect and are made in good faith. ______Signature of Applicant Subscribed and sworn to me this ______day of ______, ______month year </p><p>______Signature of Notary Public</p><p>Notary Public in the State of ______My Commission expires ______, ____ year</p><p>Payment must accompany application and may be made by check payable to the American Board of Medical Laboratory Immunology or by credit card.</p><p>To pay by credit card, please complete the section below. Visa, MasterCard, and American Express are accepted.</p><p>Credit card number Expiration  Visa  Mastercard date  MasterCard </p><p>Month Year  American Express Name as it appears on credit card </p><p>Today’s date Signature______</p><p>Month Day Year</p><p>If you would like a receipt sent to you, please check this box:  How would you like your receipt sent to you?  By email at: ______ By fax at: ______(ATTN:______)</p>