Online Training and Competency Order Form

Enrollment Information

Enrollment Information

This request is for enrollment year: *

Identification Information

Identification Information

WSLH PT ID (7 Digits)

Current/previous account ID (if known)

CLIA ID

If application in progress, enter "Pending"

Contact Information Of Person Completing This Form

Contact Information Of Person Completing This Form

Facility Name *

Contact Name *

Phone *

Example: 123-456-7890

Email *

Billing Information

Billing Information

Facility name

Contact name

Address

Apt, suite, etc.

Country

City

State

Zip code

Phone

Example: 123-456-7890

Fax

MTS Training Courses and Competency Tests

MTS Training Courses and Competency Tests

Training Courses

Choose All for 5 or more items or Individual for 1 to 4 items.

All Training Courses- Item#: PT80000 - Price: $500

Individual Training Courses- Item#: List below - Price; $100 per item

Competency Tests

Choose All for 5 or more items or Individual for 1 to 4 items.

All Competency Tests - Item#: PT81000 - Price: $500

Individual Competency Tests - Item#: List below - Price: $100 per item

Combination of both Training and Competency

All for 8 or more items combined or Individual for 2 to 7 items combined.

All of both Training and Competency - Item#: PT80900 - Price: $800

Individual Training and Competency - Item#: List below - Price: $100 per item

List Individual Item#s here

See MTS Product List for Individual Item#s.

MTS Point of Care

MTS Point of Care

Microscopy Procedures (PPMP)

PPMP Training Courses - Item#: PT80520 - Price: $300

PPMP Competency Assessment - Item#: PT81900 - Price: $300

PPMP Training and PPMP Competency together - Item#: PT81920 - Price: $500

Waived Test Kits and POC Instruments (WPOC)

If ordering with Training and/or Competency choose Add-on option.

WPOC Competency Assessment - Item#: PT81910 - Price: $300

WPOC Competency Assessment Add-on to T/C - Item#: PT81913 - Price: $200

MTS Lecture Library Subscription

MTS Lecture Library Subscription

Lecture Library Subscription

Lecture Library - Item#: PT81800 - Price: $200

Facility Fees

Facility Fees

Fee applies for facilities with more than 30 users per WSLH PT ID#

Facilities with more than 30 users complete information below.

Number of Users

Item#

PT80910

Price

$100 per Item

Fee Total

Order Total

Order Total

Price Totals

Add prices from all sections above

Annual Processing Fee

Non WSLH PT customers add $80 (2021 enrollment) or $85 (2022 enrollment)

Order Total

Add Price Totals and Annual Processing Fee (if applicable)

Payment Information

Payment Information

Purchase Order (PO#) - optional

VISA/MC: If you wish to pay by credit card, please wait for your invoice for instructions.

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