Renewal

Name
Date / Time
Address
Are you currently employed?*
1. Have you worked at least 40 hours over the past two years?
2. Have you ever had your certification suspended, revoked, or terminated by any agency or organization?
3. Have you ever been convicted of a criminal offense?
4. Do you have any outstanding disciplinary actions, investigations, or complaints?
5. Are you currently under any probation or corrective action related to your practice? Purpose: Helps evaluate current professional standing beyond past records.
6. Have you completed all required continuing education (CE) credits for this renewal cycle?
7. Do you currently hold any other healthcare certifications or licenses in good standing? (e.g., CPR, CMA, phlebotomy)
Has your contact information (address, employer, phone, email) changed since your last renewal?
9. Are you aware of and in compliance with all current continuing education and practice requirements for your certification?
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Confirmation
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