Placement Confirmation

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:  

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?  

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. 

Leave this empty:

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Signature Certificate
Document name: Placement Confirmation
lock iconUnique Document ID: 793564662d2024af72f59ac7406e8552b76c618b
Timestamp Audit
May 11, 2022 9:17 AM EDTPlacement Confirmation Uploaded by MedCertify Education - [email protected] IP
May 11, 2022 9:49 AM EDTMedCertify Documents - [email protected] added by MedCertify Education - [email protected] as a CC'd Recipient Ip:
August 25, 2022 9:59 AM EDTMedCertify Documents - [email protected] added by MedCertify Education - [email protected] as a CC'd Recipient Ip: