Recertification Application Form

Recertification Application Form

Applicant Information

Agreement Recitals

WHEREAS, Applicant Name: is a holder of the credential identified above and seeks recertification pursuant to the policies of the Certifying Organization; and

WHEREAS, Certifying Organization: administers the recertification process for the Program / Credential and requires submission of documentation, fees, and agreement to terms for renewal of the credential;

WHEREAS, the parties agree that recertification will be granted only upon satisfactory demonstration of continuing competency, payment of any required fees, and compliance with the terms set forth in this application and agreement.

Scope of Work / Recertification Activities

Describe the continuing education, audits, supervised practice, or other activities completed in support of this recertification application. Include dates, course titles, credit hours, provider names, and any identifying document references.

Payment Terms

Applicant shall pay the recertification fee as required to process this application. Fees are non-refundable except as required by applicable law and as expressly provided herein.

Term and Termination

This recertification application and any resulting renewal shall be effective as of Start Date: and, if granted, shall remain in effect through End Date: unless earlier suspended or terminated in accordance with this section.

Either party may terminate this application or any renewal for cause upon written notice delivered in accordance with the organization’s policies. For termination without cause, the providing party must deliver Notice Period (days): days' written notice.

Confidentiality

Applicant information, supporting documentation, and any proprietary materials submitted in connection with this application constitute Confidential Information of the submitting party. The Certifying Organization shall maintain confidentiality in accordance with its policies and shall not disclose such information except (a) as required by law or regulation, (b) with the Applicant’s prior written consent, or (c) to its employees or contractors with a need to know who are bound by confidentiality obligations at least as protective as those set forth herein. Upon request, the Applicant may require return or certified destruction of non-record materials.

Governing Law

This application, any agreement formed by approval of this application, and any disputes arising hereunder shall be governed by and construed in accordance with the laws of the State of , without regard to conflict of law principles.

Entire Agreement

This application, together with any written policies, procedures, or supplemental documents expressly incorporated herein, constitutes the entire agreement between the parties with respect to recertification and supersedes all prior representations, negotiations, or agreements, whether written or oral. No amendment shall be effective unless in writing and signed by an authorized representative of the Certifying Organization and the Applicant.

Supporting Documentation

Please indicate which documents are attached to this application. All documents must be legible and bear dates and provider verification where applicable.

CEU Certificates / Certificates of Completion

Official Transcripts / Training Records

Proof of Payment / Receipt

Other:

Attestation and Certification

By submitting this Recertification Application Form, the Applicant certifies under penalty of perjury that the statements made herein and the documents provided are true, accurate, and complete to the best of the Applicant’s knowledge. The Applicant acknowledges that false statements or material omissions are grounds for denial, revocation, or disciplinary action.

I certify that the information provided is accurate and agree to comply with the terms and conditions stated in this application and any resulting recertification agreement.

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