NRCM Reference Form

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This form must be completed by applicant’s current or former immediate supervisor. No letter of recommendation is required.

APPLICANT DATA

First Name *

Middle Inital

Last Name *

Email Address *

Degree

REFERENCE DATA

Reference's First Name *

Reference's Last Name *

Reference's Degree

Reference's Position Title *

Reference's Employer *

Reference's City *

Reference's State/Province

Reference's Country *

Reference's Phone Number

Reference's Business Email *

Reference's Relationship to Applicant *

How have you overseen the applicant's training and/or experience? (2000 chars left)

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APPLICANT'S POSTDOCTORAL EXPERIENCE IN THE LABORATORY

Applicant's Title (Position Held) *

Applicant's Employer/Institution *

Employer City *

Employer State/Province

Employer Country *

Dates of Applicant's Employment
Leave 'End Date' blank if currently employed. If applicant is a current CPEP Fellow, please indicate his/her expected completion date in the appropriate box above.

Start Date (mm/dd/yyyy) * End Date

Employment Information

In his/her position, does/did the applicant work full-time in a clinical, public health, reference, or other microbiology laboratory? Yes No *

If employment is/was other than full-time, please describe the extent of part-time employment (i.e., the number of hours per week) (2000 chars left)

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