Online Application for Recertification Form

Application For Recertification In:(Required)

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

Yes

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:(Required)

Full Name at time of Last Certification (If Changed):

Estimated number of hours of practice in certification specialty, within a four-year period from this date of application:(Required)

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.

Licensure Information

Check all that apply to you:

Other:

Are you currently Licensed?(Required)

Yes

Type of License:(Required)

State:(Required)

Contact Hours of Continuing Education

Number of contact hours of continuing education since last date of Certification:

Recertification 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 in Specialty:(Required)

Total contact Hours:(Required)

DO NOT SUBMIT COPIES OF CE COURSE CERTIFICATES. You will only submit your Recertification 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 Re-Certification Continuing Education Courses Log. AIHCP will conduct a number of random audits each year of its approved Re-Certification 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.

Recertification Fee

Did you pay your recertification fee?(Required)

The recertification fee is due when a student submits this form. If you have already paid the recertification fee then click yes, otherwise click no to submit payment now.

Yes, my certification fee is already paid

No, I will pay my certification fee now

Recertification Fee With(Required)

US Domestic Shipping and Handling

International Shipping and Handling

Do You Need To Pay a Late Fee?(Required)

All certified members have a six month grace period to renew their certification.

Yes, I do need to pay a late fee

No, I do not need to pay a late fee

Late Fee(Required)

Select an option below based on how many years your certification has been expired.

1-2 years: $150.00 late fee and show 75 CE hours.

2-3 years: $200.00 late fee and show 100 CE hours.

3-4 years: $250.00 late fee and show 125 CE hours.

4-5 years: $300.00 late fee and show 150 CE hours.

Total

Credit Card(Required)

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

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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