Online Application for Certification Form

Application For:(Required)

Would you like a scanned copy of your certificate emailed to you?(Required)

Yes

Student ID

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email(Required)

Enter Email Confirm Email

Phone Number

Educational Program Attended:(Required)

If you attended a different program then list it

Date of Completion:(Required)

Number of hours of Instruction:(Required)

Applicants must submit evidence of meeting a required pre-requisite for certification

Please briefly describe the documentation you are submitting with this applications: i.e. (college transcripts)

AIHCP reserves the right to contact any providers of academic programs and verify completion/attendance by applicant

File Upload

Drop files here or

Accepted file types: pdf, png, jpg, doc, docx, Max. file size: 100 MB, Max. files: 10.

Candidates may have their University/ College send an official transcript directly to the AIHCP. Photocopies of University/College transcripts are acceptable, however AIHCP reserves the right at any time to request official transcripts for evaluating certification eligibility. Have transcripts mailed to: The American Institute of Health Care Professionals, 2400 Niles-Cortland Rd. S.E. , Suite # 4 Warren, Ohio 44484

Higher Education:

Undergraduate Education:

University/College that granted Degree:

State:

City:

Degree Granted:

Date Degree was Conferred

Copy of Transcripts Included:

Yes

Copy of Transcripts Previously Submitted:

Yes

Graduate Education:

University/College that granted Degree:

State:

City:

Degree Granted:

Date Degree was Conferred:

Copy of Transcripts Included

Yes

Copy of Transcripts Previously Submitted:

Yes

Licensure

Applicants must submit a photo copy of their license or information on how their license can be verified

Any Current Licensure Held:

State of Licensure

Employment

Position

Current Employer or Place of Practice: (Or most Current)

Work Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Work Phone Number

Work Email Address

Your Supervisor or Human Resource Department Contact Information

Name of Supervisor or Human Resource Department Contact Person

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

While we do not routinely contact employers, we do reserve the right to contact employers at any time to make a verification that the information provided on this recertification application is factual and correct, as provided by the applicant. By submitting this recertification application, you are providing your permission for AIHCP, Inc. to contact your employer for any possible verifications of employment status and job description information.

Signature(Required)

By Typing your name below in the field box, you agree that this is the use of your digital signature.

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