| Personal Information |
| Application for Certification by: |
Examination
Reciprocity |
Full Name:
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| Email: |
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| Mailing Address: |
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| City: |
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| State: |
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| Zip: |
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| Phone (Area code - Number): |
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| Fax (Area code - Number): |
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| Previous Schooling |
| School or Educational Program Attended: |
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| City: |
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| State: |
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| Zip: |
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| Date of Completion (mm/dd/yy): |
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| Number of hours of instruction: |
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| Copy of curriculum or courses taken will be forwarded: |
Yes
No |
| Applicants must submit one of the following:
- a copy of their certificate of completion; or
- an official letter by the school, educational program, or instructor verifying successjul completion of the program and the number of contact hours of the education program. NOTE: if the certificate of completion does not have the number of contact hours detailed on it, then it is necessary to submit an official letter from the school, program or instructor verifying the number of hours or college credits earned.
- Applicants must submit to the ACCH, a copy of the curriculum of study for the program attended. This includes course titles, and/or course descriptions. However, if the attended school or program has already been approved by the ACCH, it is not necessary to submit evidence of curriculum. Check on the web site for school/program approvals.
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| For Applicants Applying for Reciprocity |
| Organization or Certifying Body you are currently certified by: |
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Date of certification (mm/dd/yy): |
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| Date of expiration (mm/dd/yy): |
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Candidates must submit a copy of their current certification certificate or a copy of their official letter of certification by the organization or certifying body. The ACCH reserves the right to contact such organization or body and verify certification of the applicant. If you are certified by more than one certifying association or body, only evidence of one is necessary. Please include the name of your educational program and city and state. It is not necessary to provide curriculum if you are seeking certification by reciprocity. |
| List all degrees/credentials earned to date: |
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| Method of Payment |
| Please select a payment option: |
Check
Money Order
Credit Card |
Agreement
I, the undersigned, verify that this application is complete, and to the best of my knowledge, all information provided is factual and true. I understand that failure to provide the needed information and required documentation could likely lead to delays in the processing of this application. I further understand that if any information supplied on this application is false, that I will be denied consideration for certification. I further understand that if at any time it is discovered that I have made false or misleading statements on this application, or misrepresent myself, or have provided fraudulent documentation to the ACCH, that the ACCH may rescind my certification and fellowship status. |
| Your comments or questions: |
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