Online Application for Fellowship Form

Before submitting this application for fellowship, please access the our Fellowship Page and review all the requirements for advancement to fellowship status. Make sure you meet all the requirements before submitting this application.

Application For Fellowship In:(Required)
Would you like a scanned copy of your Fellowship?(Required)
- Yes
- No
Student ID
Name(Required)
First Last
Email(Required)
Enter Email Confirm Email
Mailing Address(Required)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Billing Address(Required)
Same as previous

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Number
Date of your last certification or recertification:(Required)
Full Name at time of Last Certification or Recertification (If Changed):
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
Email
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 fellowship application is factual and correct, as provided by the applicant. By submitting this fellowship application, you are providing your permission for AIHCP, Inc. to contact your employer for any possible verifications of employment status and job description information.
Licensure Information
Check all that apply to you:
- RN
- LPN
- MD/DO
- Psychologist
- Counselor
- Social Worker
- Minister
- Educator
- Funeral Director
- RT
- Case Manager
- Other:
Other:
Are you currently Licensed?(Required)
- Yes
- No
Type of License:(Required)
State:(Required)
Contact Hours of Continuing Eudcation
Number of hours (contact hours) of continuing education since last date of Certification or Recertification:

Fellowship Continuing Education Courses Log(Required)

Press the plus sign to add more rows

Course or Program Title	Date Completed	Number of Contact Hours	Provider who conferred credits (School, organization, hospital, company, etc.)	This courses/program was related to my certification practice specialty: Yes/No

Total contact Hours:
Total contact Hours in Specialty:(Required)
DO NOT SUBMIT COPIES OF CE COURSE CERTIFICATES. You will only submit your Fellowship Continuing Education Courses Log. AIHCP reserves the right to request at any time that a certified member send in copies of all Continuing Education Certificates for all of the courses/programs that they have listed on their Fellowship Continuing Education Courses Log. AIHCP will conduct a number of random audits each year of its approved Fellowship applications and those chosen will be notified to submit copies of CE courses for verification. If chosen for audit, you will be notified by postal mail.
Fellowship Fee
Did you pay your fellowship fee?(Required)
The fellowship fee is due when a student submits this form. If you have already paid the fellowship fee then click yes, otherwise click no to submit payment now.
- Yes, my fellowship fee is already paid
- No, I will pay my certification fee now
Fellowship Fee With(Required)
- US Domestic Shipping and Handling
- International Shipping and Handling
Total
$0.00
Credit Card

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
Terms:(Required)
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 proven false, that I will be denied consideration for fellowship. 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 AIHCP, that the AIHCP will rescind my certification and fellowship status.
I agree
Signature(Required)
By Typing your name below in the field box, you agree that this is the use of your digital signature.
CAPTCHA

Employment

Your Supervisor or Human Resource Department Contact Information

Licensure Information

Contact Hours of Continuing Eudcation

Fellowship Fee