Online Application for Recertification Form

Application For Recertification In:(Required)
Would you like a scanned copy of your certificate emailed to you?(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:(Required)
Month
Day
Year
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
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 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:
- 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 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
- No, I am paying the Limited Time Certification Status Re-establishment Fee
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.
Certification Re-Establishment Fee with US or International Shipping(Required)
Choose an option for if you are located within the USA or outside of it.
- US Domestic Shipping and Handling
- International Shipping and Handling
Total
$0.00
Credit Card(Required)

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 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 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 Education

Recertification Fee