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

Graduate Name:   

Home Address:  

Phone Number:  

E-mail Address:  

Graduation Date:  

Program Completed: Clinical Medical AssistantPharmacy TechnicianPhlebotomy TechnicianMedical Administrative Assistant (MAA)MAA with Business AdministrationMAA with Billing & CodingMAA with Electronic Health RecordsMAA with EHR and B&CElectronic Health RecordsDental AssistantPersonal TrainerHelp Desk IT Support TechnicianInformation Technology ManagerInformation Technology SpecialistMicrosoft 365: Modern Desktop AdministratorCisco Certified Network AssociateCisco Certified Networking Professional - EnterpriseCompTIA A+CompTIA Network+CompTIA Security+Cyber Operations SpecialistCertified Information Systems Security ProfessionalCompTIA CASP+Information Security ProfessionalCyber Security ProfessionalCertified Lean Six Sigma Yellow BeltCertified Lean Six Sigma Green BeltCertified Lean Six Sigma Black BeltCertified Logistics Associate (CLA)Certified Logistics Technician (CLT) 

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 within1 80 days of graduation or receiving NHA/AMCA Certification. Employment will be verified after 30 days. To be considered, employment must be full-time.

Place of Employment:  

Name of Employer/Contact Person:  

Business Address:  

Business Phone Number:

Business Email:    Date Of Employment

Job Title:  

Job Duties:

Wage Per Hour: $   Total Hours Per Pay Period:  

Who Is Providing This Information:  

Does the Student Need Placement Assistance? YesNo 

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. 

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Your legal name

Your email address

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Signature Certificate

Document name: Placement Confirmation

Unique Document ID: 793564662d2024af72f59ac7406e8552b76c618b

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Timestamp	Audit
May 11, 2022 9:17 AM EDT	Placement Confirmation Uploaded by MedCertify Education - [email protected] IP 99.190.9.234
May 11, 2022 9:49 AM EDT	MedCertify Documents - [email protected] added by MedCertify Education - [email protected] as a CC'd Recipient Ip: 99.190.9.234
August 25, 2022 9:59 AM EDT	MedCertify Documents - [email protected] added by MedCertify Education - [email protected] as a CC'd Recipient Ip: 99.190.9.234

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