<p> Use this verification Use this verification form if you are VERIFICATION form if you are applying under applying under Route 2 or Route 3 FORMPage 1 of 6 2007 Certification Exam Route 2 or Route 3</p><p>To the Applicant: Please complete these four steps...</p><p>1. Print your complete name.</p><p>FIRST: ______MIDDLE: ______</p><p>LAST: ______</p><p>2. Read and sign this waiver.</p><p>--Waiver--</p><p>In accordance with the provision of the Family Educational Rights and Privacy Act of 1974, P.L. – 390 (as amended), with specific reference to Section 438 (a) (1) (B) and subtitle A sections 99.7, 99.11, and 99.12:</p><p>I understand that federal legislation provides me with a right of access to this recommendation after I matriculate; while this right may be waived, no school or person can require me to waive this right.</p><p>You must select one of these two options:</p><p>极 I waive my right of access to this recommendation.</p><p>极 I do not waive my right of access to this recommendation.</p><p>Applicant’s Signature Date VERIFICATION</p><p>FORMPage 2 of 6 VERIFICATION</p><p>FORMPage 3 of 6</p><p>3. Get two different signatures on this page. The people signing must be a Certified Medical Dosimetrist, a Medical Physicist or a Radiation Oncologist.</p><p>Name and Title </p><p>Organization </p><p>Street Address </p><p>City State Zip </p><p>Phone E-mail </p><p>I certify that, to the best of my knowledge, the information contained in the application regarding education, training and work experience in medical dosimetry is correct and complete</p><p>Signature Date </p><p>Name and Title </p><p>Organization </p><p>Street Address </p><p>City State Zip </p><p>Phone E-mail </p><p>I certify that, to the best of my knowledge, the information contained in the application regarding education, training and work experience in medical dosimetry is correct and complete</p><p>Signature Date </p><p>Submit the entire VERIFICATION FORM (pages 1-5) to your immediate supervisor (the 4. recomender). </p><p>That’s all you need to do, the recommender does the rest. (The recommender will complete the rest of this form and fax it to MDCB.) VERIFICATION</p><p>FORMPage 4 of 6</p><p>To the Recommender: </p><p>The individual named on page 1 has applied to take the 2007 Medical Dosimetrist Certification Exam.</p><p>We are seeking any and all information that will aid us in the selection of this applicant for the Certification Exam. This applicant has identified you as an immediate supervisor who can provide a candid evaluation of their qualifications. As the recommender, you must be a Certified Medical Dosimetrist, Medical Physicist or Radiation Oncologist.</p><p>If the applicant has waived his or her right of access (page 1), your recommendation will remain confidential. If the applicant does not waive right of access or sign the waiver statement, the applicant will be permitted to review this reference upon request.</p><p>We realize that you may be asked to provide numerous letters of recommendation for applicants seeking to sit for the exam. On behalf of both the applicants and MDCB, we thank you in advance for your attention to this matter and are very appreciative of your efforts.</p><p>There are five steps for you to complete. They start on page 4.</p><p>Please fax the entire completed Verification Form to (800) 648-1828 no later than Wednesday, March 1, 2007.</p><p>If you have any questions, please contact us at [email protected].</p><p>Thank you.</p><p>MDCB VERIFICATION</p><p>FORMPage 5 of 6</p><p>To the Recommender: Please complete these five steps...</p><p>1. How long and in what capacity have you known this applicant?</p><p>2. Please include any additional comments that will aid us in obtaining a complete picture of this applicant’s abilities and potential as a Certified Medical Dosimetrist.</p><p>3. Personal and Professional Appraisal VERIFICATION</p><p>FORMPage 6 of 6</p><p>4. Please rate this applicant:</p><p>1 = Poor 2 = Average 3 = Good 4 = Excellent N/A= Applicable</p><p>Academic Potential Motivation for a Career in Medical Dosimetry Leadership Skills Sense of Responsibility Technical Skills Ability to Work with People Oral Communication Skills Ability to Adapt to New Situations Written Communication Skills Ability to Work Independently Problem Solving Skills Reliability</p><p>Your overall recommendation for this applicant (select one): 极 Strongly recommend 极 Recommend 极 Recommend with reservations 极 Do not recommend</p><p>5. The applicant’s training </p><p>Location of Training: ______</p><p>Training Supervisor: ______Title: ______</p><p>Phone: ______</p><p>Dates of Training: (month/year) From: ______To: ______</p><p>Total months spent in OJT: ______This must be more than: 24 months for Route 2 applicants 36 months for Route 3 Applicants</p><p>______Signature of Training Supervisor: Date</p>