Application for Certification by: _____ Examination _____ Reciprocity _____ Practice Experience

Name:____________________________________________________________________ Date :_____________

Mailing Address:______________________________________________________________________________

City:____________________________________ State:_____________ Zip:____________________________

Phone:__________________________________ Fax:________________________________________________

Email Address:________________________________________________________________________________

LNC School or Educational Program Attended:____________________________________________________

Date of Completion:_________________________________ Number of hours of instruction:______________

Applicants must submit one of the following: 1) a copy of their certificate of completion, or 2) an official letter by the school, educational program, or instructor verifying successful completion of the program and the number of contact hours of the educational 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.

For translation purposes, the ACLNC uses the following conversion: 50 minutes = 1 contact hour. 1 semester unit of college credit = 15 contact hours.

For Applicants applying for Reciprocity

Organization or Certifying Body you are currently certified by:_______________________________________

Date of certification:__________________________________ Date of expiration:________________________

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 ACLNC reserves the right to contact such organization or body and verify certification of the applicant.

For applicants applying for Certification qualification by practice experience

Employer:____________________________________________________________________________________

If self employed, name of business:_______________________________________________________________

City:__________________________________ State:__________________ Zip:_________________________

Phone:______________________________________ Fax:____________________________________________

Number of hours of practice as an LNC within a three year period from this date of application:___________

Applicants must have two reference letters from current or former clients ( attorneys, insurance company, etc) attesting to the fact that the LNC had done work for them, and a short reference related to quality of work product. Reference letters must be sent directly to the office of the ACLNC. Applications will be considered pending until references are received.

44446.

List all degrees/credentials earned to date: _____________________________________________________________________________________________

_____________________________________________________________________________________________

Method of Payment

Application fee for 3 year term of certification is $ 150.00

_____ Check

_____ Money Order

_____ Credit Card _____ Visa _____ MC

Card Number:____________________________________________________ Expiration:_________________

 Name on Card:___________________________________________________ Signature:___________________

_____________________________________________________________________________________________

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 provided 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 untrue statements on this application, or misrepresented myself, or have provided fraudulent documentation to the ACLNC, that the ACLNC may rescind my certification and fellowship status.

Agreed:

______________________________________________________________ Date:________________________

Signature