Transcription of RECERTIFICATION/REACTIVATION BY CCP FORM
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RECERTIFICATION/REACTIVATION BY CCP FORM
Indicate the certification type for which you are seeking recertification or reactivation. Check all that apply: Medical Technologist (MT) Medical Laboratory Technician (MLT) Registered Medical Assistant (RMA) Registered Dental Assistant (RDA) Registered Phlebotomy Technician (RPT) Allied Health Instructor (AHI) Certified Medical Administrative Specialist (CMAS) Certified Laboratory Consultant (CLC) Certified Medical Laboratory Assistant (CMLA) _____ First Name Middle Initial Last Name _____ Street Address City/State Zip Code _____ E-mail Address Home Phone Number Work Phone Number _____ Maiden Name Date of Birth Year Certified by AMT _____ AMT ID# Social Security Number NOTE.
Return this form by fax: 847-789-8516, scan/email: ccp@americanmedtech.org or to AMT at the address below American Medical Technologists, 10700 West Higgins Road, Suite 150, Rosemont, IL 60018
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