Felony Information Checklist

Felony Information Checklist

AMT will not review documentation prior to an application being submitted.

Please be sure to complete all fields and submit in a timely fashion.

General Information
Even if a candidate meets certification eligibility criteria, AMT may determine that certain types of felony convictions in an applicant's background may preclude an applicant from sitting for an AMT certification examination. Even if an applicant with one or more felony convictions in his or her record is permitted to take the examination and passes it and becomes certified, some healthcare employers may choose not to hire any individual who has been convicted of a felony, even if he or she is certified. Certification is not a guarantee of employment.

Review of Documentation
All submissions must be accompanied by the following documentation: copies of all available supporting documentation, specifically explaining the date of the felony, nature of the felony, a personal statement describing the felony and events that took place, and any available court documents. All materials must be provided to AMT in a single submission. Incomplete submissions will not be processed.

Each application is reviewed carefully on a case-by-case basis by the AMT Office before a determination is made. AMT will render a decision and notify applicants within 30 days of receiving the application. If deemed ineligible to sit for an AMT certifying examination , the applicant may appeal the decision.

For additional information on the appeals process, please contact the AMT Certification Experience Team at documents@americanmedtech.org.

AMT ID number*

Member Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

example@example.com

Phone Number*

Area CodePhone Number

Certification*

Were you actually convicted of a felony?*

YesNo

The felony was for (Select all that apply)*

N/A If other selected, please specify type of felony

When did the felony take place?*

After the conviction, was jail/prison time served?*

YesNo

Are you still in jail/prison?*

YesNo

When were you released from jail/prison?*

When is your expected release date?*

Are you currently on probation/parole?*

YesNo

When did your probation/parole end?*

When is your probation/parole expected to end?*

Please provide a personal statement including a DETAILED description and explanation of the felony and events that took place.

Personal Statement*

Each applicable item must be submitted to AMT for review and approval before being permitted to schedule an exam.

Copies of any court documents
Copies of probation release forms
3 signed character reference letters (letters will not be accepted from family /friends)

Attach all supporting and court documentation. *

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Certification
I certify that the information I have provided is true and correct to the best of my knowledge and belief, and I understand that certification is subject to revocation for misrepresentation of any information. I further understand that even with AMT certification, some medical care employers will not hire individuals with felony convictions.

Agreement*

By electronically signing this document I attest to this information being correct.

Please verify that you are human*

N/A -Description of Felon

N/A

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Contact Information

Felony Information

Felony Description & History

Supporting/Court Documents