Letter of Standing Request Form

Date
Name *
Please provide your name
NSCMLT # *
Please provide your NSCMLT #

Mailing Address

Street *
Please provide your street address
City / Town *
Please provide your city
Province *
Please select your province
Postal Code (A1A 1A1) *
Please type your postal code in the following format: A1A 1A1.
Regulatory Body requesting letter *
Please provide the regulatory body requesting this letter
Date required *
Please let us know the date required
I verify that I will no longer be employed as a MLT in Nova Scotia as of *
Please provide a date when you will no longer be employed as a MLT in Nova Scotia
Method of Payment

Please select a method of payment
Total Member $50.00
Former Member $75.00
Make cheque payable to: Nova Scotia Society of Medical Laboratory Technologists
Reference # to be printed on cheque:
Mail to:
380 Bedford Highway, Suite 202
Bedford, NS B3M 2L4


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Total 0.00 CAD