MLT, MLS, CT, H, and PA Application - WV Clinical Laboratory Practitioners

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Demographic Information


First Name	Middle Name	Last Name	Suffix
Maiden Name	Former Name	Social Security # Social security numbers are used solely for identification purposes and will never be shared unless required by law.	Date of Birth
Contact Information

Contact Information


Address Line 1		Address Line 2
City	State	ZIP Code
Phone	Primary Email	Secondary Email Enter your supervisor’s email here if they should receive approval notices

Account Information

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Password


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Passwords must be at least 8 (eight) characters in length and include at least 1 (one) uppercase letter, lowercase letter, number and special character. *Special characters allowed are @ ! $ % & ( ) - [ ] { } , / : ?**
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Please make note of your username and password and keep them in a secure place. You will need them to log into your saved application, access application information and later if your license is approved.

License Category and Route

Pathologist Assistant (PA)

Medical Laboratory Scientist (MLS)

Medical Laboratory Technician (MLT)

Cytotechnologist (CT)

Histologist (H)