2023 InService Exam - Invoice Request Form

This form is for Fellowship Programs who would like to pay the registration fee for the 2023 ACMT Medical Toxicology Inservice Exam on behalf of their fellow(s).


After this form is submitted, ACMT Staff will email an invoice to the Program Contact provided on this form.


After payment is received, ACMT Staff will email the Program Contact a registration code to give to the Program's fellows. When the fellows register themselves for the exam, they will use this registration code and will not have to pay the registration fee. (They will still have to go through the process of registering themselves, but the code will give them a zero balance at checkout.)


Questions? Write to Sr. Program Manager Dana Karshenas at dana.turner@acmt.net.

Please select your program location from the dropdown list.

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Registration Info

How many exam registrations would your fellowship program like to purchase?

List the FIRST and LAST names of all fellows for whom you are purchasing exam registrations.

Fellowship Program Contact

Address Invoice To:

Optional. Please provide the name of the billing contact to whom the invoice should be addressed, if different from the Program Contact.

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