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

Application in progress, CLIA ID not yet received

Contact Information Of Person Completing This Form

Contact Information Of Person Completing This Form

Facility Name *

Contact Name *

Phone *

Example: 123-456-7890

Email *

MTS Training Courses and Competency Tests

MTS Training Courses and Competency Tests

Choose All or Individual option.

See MTS Product List for Individual Item#s.

Training Courses

All Training (ordering 5 or more items)

Individual Training (ordering 1 to 4 items)

Item#

PT80000

List in space below

Price

$500

$100 per item

Competency Tests

All Competency (ordering 5 or more items)

Individual Competency (ordering 1 to 4 items)

Item#

PT81000

List in space below

Price

$500

$100 per item

Combination of Training and Competency

All of both (ordering 8 or more combined items)

Individual (ordering 1 to 7 combined items)

Item#

PT80900

List in space below

Price

$800

$100 per item

List Individual Item#s here

MTS Point of Care Competency Assessment

MTS Point of Care Competency Assessment

To order Point of Care Competency Assessment choose circle below.

If ordering with Training Courses and/or Competency tests choose w/T&C option.

Microscopy Procedures (PPMP)

Ordering Microscopy Procedures alone

Ordering Microscopy Procedures w/T&C

Item#

PT81900

PT81903

Price

$300

$200

Waived Test Kits POC Instruments

Ordering Waived Test Kits POC alone

Ordering Waived Test Kits POC w/T&C

Item#

PT81910

PT81913

Price

$300

$200

MTS Lecture Library Subscription

MTS Lecture Library Subscription

Lecture Library Subscription

Order Lecture Library Subscripton

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

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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