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 *

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.

All - Training Courses

Item#: PT80000 - Price: $500

5 or more items

Individual - Training Courses

Item#: List below - Price: $100 per item

1 to 4 items

All - Competency Tests

Item#: PT81000 - Price: $500

5 or more items

Individual - Competency Tests

Item#: List below - Price: $100 per item

1 to 4 items

All of both - Combination of Training and Competency

Item#: PT80900 - Price: $800

8 or more items

Individual - Combination of Training and Competency

Item#: List below - Price: $100 per item

2 to 7 items

List Individual Item#s here

MTS Point of Care Competency Assessment

MTS Point of Care Competency Assessment

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

Microscopy Procedures (PPMP) - alone

Item#: PT81900 - Price: $300

Microscopy Procedures (PPMP) - w/T&C

Item#: PT81903 - Price: $200

Waived Test Kits POC Instruments - alone

Item#: PT81910 - Price: $300

Waived Test Kits POC Instruments - w/T&C

Item#: PT81913 - Price: $200

MTS Lecture Library Subscription

MTS Lecture Library Subscription

Lecture Library Subscription

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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Contact WSLH Proficiency Testing | (800) 462-5261 | ptservice@slh.wisc.edu |