Section I. - To be filled out by Applicant

Name:     Cert Yr: Cert #
Address:  Telephone #
City:    State/Province: Zip/Postal Code: 
E-mail:	 

Attach the following items to this application and mail or fax to NAHUC Certification Board:

• Method of payment $75 ($50 with copy of current NAHUC membership card)
   Money order or check payable to NAHUC Certification
   Charge my  VISA    MasterCard 
        (a $5 processing fee will be added to credit card payments)

• Fees paid to NAHUC Certification Board are non-refundable.
  
  Card # Exp. Date:

I have read and complied with all instructions in the Recertification Manual.  I have completed 36 hours of continuing education within the three years prior to my recertification expiration date.  I state that my educational activities are related to the NAHUC Certification Exam Content Outline.  I state that any non-NAHUC activities have been previously submitted and approved for conversion to NAHUC contact hours. I understand that educational activities that relate only to the internal policies of one institution, hospital orientation, department meetings, CPR and mandatory annual fire/safety programs are not applicable toward recertification.  I understand I am responsible for keeping documentation of all continuing education and that all educational activities are subject to verification.  I ascertain that all my contact hour certificates are valid and contain no falsified information.  I understand my recertification application is subject to review and audit prior to approval.  I agree that, upon request, I will submit all documentation of 36 hours of continuing education to the NAHUC Certification Board within 30 days of receipt of request.  I understand that failure to comply will result in the revocation of my certification.

Signature:_________________________________ Date:__________________________

Section II a. - To be filled out by NAHUC Certification Board
Postmark:   
Application for Recertification Accepted Rejected
Application for Recertification rejected and returned to applicant for:
New Recertification Period:
__________________________________________________________________________
Section II b. - To be filled out by NAHUC Education Board
Request for documentation sent to applicant:

Return documentation postmarked:

Application for Recertification and Documentation Accepted Rejected

Application for Recertification rejected and returned to applicant for:

New Recertification period:

It is verified that above applicant (has, has not) met the established requirements and (should, should not) be granted a Certificate of Continuing Professional Excellence.

Signature/Title:____________________________________ Date:__________________