ABMLI Reference Form

Must be completed by applicant’s current or former immediate supervisor.

No letter of recommendation is required.

I. APPLICANT DATA:
First Name:
Middle Initial:
Last Name:

II. REFERENCE DATA:
First Name:
Last Name:
Degree:
Position Title:
Employer:
City:
State:
Country:
Phone Number:
Business Email:
Relation to Applicant:
How have you overseen the applicant's training and/or experience?:
 

III. APPLICANT'S POSTDOCTORAL EXPERIENCE IN THE LABORATORY:
Please complete with the applicant’s information while under your supervision.
Applicant's Title:
Applicant's Employer (Institution):
Employer City:
Employer State:
Employer Country:

Dates of applicant’s employment
(mm/dd/yyyy) to (mm/dd/yyyy):

   to   (leave blank if currently employed)
If employment was other than full-time,
please describe the extent of part-time
employment (i.e., the number of
hours per week):
If the applicant completed a training
program under your supervision,
was it accredited by the
Committee on Postgraduate
Educational Programs (CPEP)?
Yes No
If you answered “Yes” you may skip the section below.
 
Below, please describe the applicant’s duties, giving percentages of time devoted to each of the following areas. Please specify if the duties were hands-on experience or learned as part of a training program. Refer to the ABMLI eligibility requirements for specific requirements.  
The percentages entered below must add up to 100%.
%
Administrative and Management Activities
Please provide a detailed description
Description:
   
% Diagnostic and Clinical Service
Please provide a detailed description
Description:
   
% Research
Please provide a detailed description
Description:
   
% Teaching
Please provide a detailed description
Description:
% Other
Please provide a detailed description
Description:
% TOTAL
   
Additional Comments: . Please provide additional information as to why you would recommend this applicant for certification.  

IV. VERIFICATION
By checking this box, I verify that all the information on this page is complete and accurate to the best of my knowledge.