This form must be filled out in its entirety.
Leave employer blank unless it is related to the program you completed.
The content on this form is used for licensing requirements and is mandatory for all students and graduates.
Student Information
Employment Information
Please list only related information to the program you completed. Leave this area blank if you are seeking employment in the related field. It will be completed once placed in the field. Employment in the field must occur within 180 days of graduation or receiving NHA/AMCA Certification. Employment will be verified after 30 days. To be considered, employment must be full-time.
I hereby authorize and give consent to MedCertify to contact my employer for employment verification information needed for state licensure compliance as well as federal and authorized workforce agencies for career placement records.