Application Form Instructions

Application & Reference Forms

National Registry of Microbiologists

Rev. 6/12/07

APPLICATION FORM INSTRUCTIONS

• Before completing the application form, carefully review the NRM eligibility information to be certain you meet the stated requirements.

• To prevent delays in processing, fill in all information blanks on the application form and submit the following:

1. Notarized application form.

1. Official transcript(s) or transcript evaluation(must be sent directly to the NRM by the issuing institution).

1. Notarized copy of your marriage license or name change certificate (only if the name on your transcript does not match the name on your application and reference forms).

1. Reference form(s) documenting the minimum work experience requirement (may be mailed separately or with the application; must be original).

1. Documentation of workshop attendance (if applicable).

1. Application fee.

Certification Examination and Deadline / Fee
Registered / Specialist
Industrial microbiology
April 1 (early bird) / $207 ($150 ASM member) / $232 ($175 ASM member)
July 1 (regular) / $232 ($175 ASM member) / $257 ($200 ASM member)
Biological safety microbiology
April 1 (early bird) / – / $232 ($175 ASM member)
July 1 (regular) / – / $257 ($200 ASM member)

An additional shipping surcharge of $40 will be assessed for examinations and reexaminations held outside the United States, Puerto Rico, and Canada. If paying by check, please add this surcharge to your application fee. If paying by credit card, the surcharge will be added.

Mail application to:

National Registry of Microbiologists

1752 N Street, NW

Washington, DC 20036-2904

FEE POLICIES

• All incomplete and/or ineligible applications will be withdrawn with a refund of the application fee minus a 25% administration fee.

• If an applicant is found eligible for examination, s/he must take the examination within two examination administrations of the application’s approval date.

• Examinations must be passed within threeexamination administrations of the application’s approval date. Reexamination after the expiration of this time period requires a new application with full fee.

• The current reexamination fee for registered microbiologist examinations is $75 for ASM members and $132 for non-members. The current reexamination fee for specialist microbiologist examinations is $100 for ASM members and $157 for non-members.

• Once an examination has been scheduled, no refund will be issued if the applicant cancels his/her sitting.

National Registry of Microbiologists

/ 1752 N Street, NW
Washington, DC20036-2904
(202) 942-9281 telephone
(202) 942-9353 fax

APPLICATION FORM

RevisedOctober 2006 / IMPORTANT: Type or print clearly and complete all sections.Do not staple.

I. Examination Category: Check the appropriate category below.

Registered Microbiologist
RM(NRM) /  Consumer Products/Quality Assurance Microbiology Conditional Registrant ______
Select your specialty area below
Pharmaceutical/Medical Device/Cosmetics OR  Food & Dairy
Specialist Microbiologist
SM(NRM) / Consumer and Industrial Microbiology(Pharmaceutical/Medical Device/Cosmetics)
 Biological Safety Microbiology

1. Biographical Data: Notify the NRM immediately of any changes in your contact information.

Name (First, M.I., Last):
Mailing address: / Daytime phone number:
E-mail address:
Fax number:
U.S. Social Security number:
ASM member number (if applicable):
Gender:  Male  Female
Print your name here as you wish it to appear on your certificate:
How did you first hear about NRM certification?  Ad in Microbe  Ad in an ASM Journal ASM Website  ABSA Website Co-worker
 HR/Supervisor NRM Registrant  Other (please specify) ______
If you were referred by an NRM registrant, please name:
Who is paying your application fee? I am  My employer is

1. Proctor:Once your application has been approved by the NRM, you will be instructed to arrange for an eligible proctor and approved examination

site. If you already know who your proctor is, please enter the proctor’s information below.

Name: / Daytime telephone:
Title: / E-mail address:
Federal Express mailing address (no post office box): / Fax number:
Describe your relationship to proctor:

If you plan to take the biological safety examination at the American Biological Safety Association meeting, please check here: 

IV.References:All references must be submitted on NRM reference forms (letters will not be accepted). References must be filled out by your supervisor and document the minimum work experience requirement.

Name / Employer

V. Experience in the Laboratory: Total amount of laboratory experience: ______years ______months

Current employer / City, state / Dates of employment
to
Supervisor name, title:
Type of current employment: check one box only. /  Federal government laboratory /  Pharmaceutical
 Biotechnology /  Food industry /  Reference laboratory
 Biological safety facility /  Hospital /  State/public health laboratory
 Cosmetics /  Medical school /  University/college
 Environmental /  Military laboratory /  Other: ______

V.Experience in the Laboratory (continued):

Past employer name(s) / City, state / Name of supervisor / Dates of employment
to
to
to
to
to

VI.Academic Education: All educational requirements must be met through institutions accredited by a regulatory agency recognized

by the U.S. Department of Education.

Institution / Location / Major subject / Degree
Type / Date conferred

1. Academic Education(continued): List all microbiology courses. If microbiological content is not apparent from the course title, a copy of the course description verifying the course content must be included with the application. A description from the course catalog or anotherofficial source is sufficient.

Institution / Course Number / Name of course / Semester/quarter hours
Total microbiology credit hours

VII. Microbiology Workshops: Attendance at approved microbiology workshops may be substituted for up to four (4) semester hours or six (6) quarter hours of microbiology coursework. Eight (8) workshop hours = 0.5 semester hours or 0.75 quarter hours of coursework. Approved workshop sponsors are the ASM, the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), andthe International Association for Continuing Education and Training (IACET).

All courses must have been completed within the last four (4) years. You must submit a copy of the certificate of attendance.

Workshop Sponsor / Workshop Title / Credits / Date
Total workshop credit hours

VIII. Affidavit:

State of ______, County of ______

I, ______, do solemnly swear (affirm) that I am the applicant named in this application; that I have made or read the contents hereof; that I have read and understood the contents of the National Registry of Microbiologists Application Kit; and that to the best of my knowledge and belief the foregoing statement and answers are true in substance and effect and are made in good faith.

______

Signature of Applicant

Subscribed and sworn to me this ______day of ______, ______

month year

______

Signature of Notary Public

Notary Public in the State of ______My Commission expires ______,______

Payment must accompany application and may be made by check, payable to the National Registry of Microbiologists, or by credit card.

To pay by credit card, please complete the section below. Visa, Mastercard, and American Express are accepted.

 Visa
 Mastercard
 American Express
 Eurocard / Credit card number: / Expiration
 MasterCard / date:
 American Express / Month / Year
Name as it appears on credit card: car
Today's Date: / Signature: ______
Month Day Year

National Registryof Microbiologists

/ 1752 N Street, NW
Washington, DC20036
(202)942-9281 telephone
(202) 942-9353 fax

REFERENCE FORM

Revised October 2006 / IMPORTANT: Type or print clearly and complete all sections. Do not staple.
To be filled out by applicant’s current or former supervisor.

I.Applicant Data:

Applicant’s Name (First, M.I., Last):

II.Reference Data:

Name: / Function of company: /  Academic ___ 2 year ___ 4+ year
 Medical/health professional school
 Federal/state/local government laboratory
 Private/commercial laboratory:
___ clinical ___ testing
 Hospital
 Private industry: type______
 Private research: type______
 Other: ______
Title:
Employer:
Mailing address:
Telephone:
E-mail address:
Relationship to applicant:

III.Applicant’s Employment: Dates of applicant’s employment | | to | | ( ____ years and ____ months).

If employment was other than full-time, please describe the extent of part-time employment(i.e., the number of hours per week, percent of time per week).

Check what you judge to be the most accurate description of the applicant's employment and the position held.
 Clinical laboratory
 Public health laboratory
 Research laboratory /  Consumer products laboratory
 Quality control laboratory
 Industrial laboratory /  Biological safety
 Trainee (please attach description of training program)
 Other: ______
Position held:

Check () the category(ies) that best describes the applicant's area of employment regardless of his/her occupation title.

General microbiology
 agricultural
 antimicrobials
 clinical/medical
 cytology/morphology/cell structure
 environmental/aquatic
 food production/testing
 genetic/molecular/physiological
 industrial
 taxonomy
 veterinary
 pharmaceutical
Bacteriology
Biochemistry
Biological Safety / Biophysics
Botany
Chemistry
Immunology
 immunochemistry
 immunoserology
 molecular
 pharmaceutical
 research
 product development
 testing
Medicine / Medical Technology
Mycology
 medical/clinical
 industrial
 pharmaceutical
 research
 testing
Parasitology
 medical/clinical
 animal
 pharmaceutical
 research
 testing
 product development / Protozoology
Virology (general)
 clinical/medical
 bacteria
 plant
 animal
 pharmaceutical
 research
 testing
 other:______
Zoology
Other: ______

Estimate the amount of time the applicant devotes to each activity listed below.

Basic research / % / Quality control/quality assurance / % / Biological safety / %
Applied research / % / Production / % / Teaching / %
Diagnostic service/training / % / Inspection / % / Administration/management / %
Analytical service / % / Consulting / % / Marketing/sales/services / %
Other: ______/ %

Briefly describe the applicant's duties:

Have any employment activities been:

Concurrent with a formal graduate study program? yes no If yes, please elaborate:

Concurrent with a formal training program? yes no If yes, please include detailed information concerning number of hours employed, type of experience obtained, etc. Participation in a training program will be evaluated on an individual basis. Attach additional information if necessary.

VI. Evaluation:Evaluate the applicant's capacity to function as a microbiologist within the laboratory. If the applicant is a supervisor, please evaluate his/her supervisory skills as well.

V.Additional Information/Comments:

VI.Signed: ______Date: ______

THANK YOU!