STUDENT INFORMATION:

Student Name:

Student Street Address:   City:  

State: AlabamaAlaska ArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisiana MaineMarylandMassachusettsMichiganMinnesotaMississippiMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth Carolina North DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashington West VirginiaWisconsin Wyoming Zip Code:  

Email Address:   Phone Number:  

Program: Associate Project ManagementBusiness AdministrationClinical Medical Assistant Cloud Computing SpecialistCybersecurity AnalystDental AssistantEKG Technician Electronic Health RecordsHuman Resource SpecialistIT HelpDesk TechnicianIT Network TechnicianIT Security SpecialistMedical Administrative AssistantMedical Administrative Assistant with Business AdministrationMedical Administrative Assistant with Electronic Health RecordsMedical Administrative Assistant with Electronic Health Records and Medical Billing & CodingMedical Administrative Assistant with Medical Billing & CodingMedical Billing & CodingMicrosoft 365 Certified: Modern Desktop Administrator AssociatePatient Care TechnicianPayroll SpecialistPC TechnicianPersonal TrainerPharmacy Technician Phlebotomy TechnicianPhlebotomy-Cardio TechnicianSurgical Technologist 

Start Date

Graduate or Current Student? GraduateCurrent Student 

PLACEMENT CONFIRMATION:

Please put any type of Employment, whether in-field or out-of-field. If not employed, please put "Not Employed" in Required Boxes.

Place of Employment:  

Name of Employer/Contact Person:  

Business Street Address:  

City:    State: StateAlabamaAlaska ArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisiana MaineMarylandMassachusettsMichiganMinnesotaMississippiMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth Carolina North DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashington West VirginiaWisconsin Wyoming   Zip Code:  

Business Phone Number:   Business Fax Number:  

Business E-Mail:  

Date of Employment:

Job Title:  

Please List Four Job Duties:

Job Duty #1:  

Job Duty #2:  

Job Duty #3:  

Job Duty #4:  

Wage Per Hour:    Total Hours per Week:  

I, , authorize and give consent to TMIKY Online to contact my employer and obtain employment verification needed to maintain licensure requirements and placement tracking records. 

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Signature Certificate

Document name: Placement Confirmation

Unique Document ID: 99008fcd4ce8a388ac99dc54a7ff2fa2b133db1b

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Timestamp	Audit
July 26, 2022 11:52 am EDT	Placement Confirmation Uploaded by Cassie Black - [email protected] IP 99.190.9.234
July 27, 2022 9:46 am EDT	CCT Documents - [email protected] added by Cassie Black - [email protected] as a CC'd Recipient Ip: 99.190.9.234
September 22, 2022 8:39 am EDT	CCT Documents - [email protected] added by Cassie Black - [email protected] as a CC'd Recipient Ip: 99.190.9.234
September 22, 2022 8:39 am EDT	CCT Documents - [email protected] added by Cassie Black - [email protected] as a CC'd Recipient Ip: 99.190.9.234
September 22, 2022 8:42 am EDT	CCT Documents - [email protected] added by Cassie Black - [email protected] as a CC'd Recipient Ip: 99.190.9.234

This audit trail report provides a detailed record of the online activity and events recorded for this document.

https://choicecareertech.com/

Audit Trail Serial# 15ca33d0b68473b453b341e957b6837b