Trainee Application - WV Clinical Laboratory Practitioners

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Demographic Information


First Name	Middle Name	Last Name	Suffix
Maiden Name	Former Name If the name on your education document differs from your current name, you must report your previous name(s). If you have >1, list all and separate with a comma.	Social Security Number Social security numbers are used solely for identification purposes and will never be shared unless required by law.	Date of Birth
Social security numbers are used solely for administrative and statistical purposes. They serve as unique personal identifiers and will never be shared or sold to other companies or agencies.
Contact Information

Contact Information


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

Account Information

Enter your username and password to create an account.

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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 @ ! $ % & ( ) - [ ] { } , / : ?**
Enter a password:	Retype the password:

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.