If you are human, leave this field blank.Online Training and Competency Order FormEnrollment 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 IDIf 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: 123-456-7890Email *MTS Training Courses and Competency Tests MTS Training Courses and Competency Tests Training CoursesChoose All for 5 or more items or Individual for 1 to 4 items.All Training Courses- Item#: PT80000 - Price: $500Individual Training Courses- Item#: List below - Price; $100 per itemCompetency TestsChoose All for 5 or more items or Individual for 1 to 4 items.All Competency Tests - Item#: PT81000 - Price: $500Individual Competency Tests - Item#: List below - Price: $100 per itemCombination of both Training and CompetencyAll for 8 or more items combined or Individual for 2 to 7 items combined.All of both Training and Competency - Item#: PT80900 - Price: $800Individual Training and Competency - Item#: List below - Price: $100 per itemList Individual Item#s hereSee MTS Product List for Individual Item#s.MTS Point of Care MTS Point of Care Microscopy Procedures (PPMP)PPMP Training Courses - Item#: PT80520 - Price: $300PPMP Competency Assessment - Item#: PT81900 - Price: $300PPMP Training and PPMP Competency together - Item#: PT81920 - Price: $500Waived Test Kits and POC Instruments (WPOC)If ordering with Training and/or Competency choose Add-on option.WPOC Competency Assessment - Item#: PT81910 - Price: $300WPOC Competency Assessment Add-on to T/C - Item#: PT81913 - Price: $200MTS Lecture Library Subscription MTS Lecture Library Subscription Lecture Library SubscriptionLecture Library - Item#: PT81800 - Price: $200Facility 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 UsersPlease select30 to 100 users (1 item)101 to 200 users (2 items)201 to 300 users (3 items)301 to 400 users (4 items)401 to 500 users (5 items)501 to 600 users (6 items)Item#PT80910 Price$100 per Item Fee TotalOrder Total Order Total Price TotalsAdd prices from all sections aboveAnnual Processing FeeNon WSLH PT customers add $80Order TotalAdd Price Totals and Annual Processing Fee (if applicable)Payment Information Payment Information Purchase Order (PO#) - optionalVISA/MC: If you wish to pay by credit card, please wait for your invoice for instructions. Verification *reCAPTCHA is required.This step is to verify this form is being completed by a person and not a computer.Submit Contact WSLH Proficiency Testing | (800) 462-5261 | ptservice@slh.wisc.edu |