2018 Certification Cycle Extension Request

2019 Certification Cycle Extension Request Form

In order to maintain your certification you may submit a Certification Cycle Extension Request form. To be eligible for approval, you must meet the following requirements: Certification cycle must end December 31, 2018, the form must be submitted by December 31, 2018, you must be a certified member, your membership dues must be up to date, and an extension request cannot have been approved previously.

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Name*
First Last
Member ID*
Email*

Requirements
Have you previously received a certification cycle extension?*
Yes
No
Does your certification cycle end December 31, 2018?*
Yes
No
Does your membership expire June 30, 2019 or later?*
Yes
No
We will not be able to process this form. In order to be eligible for an extension request, you cannot have previously received one.
We will not be able to process this form. In order to be eligible for an extension request, your certification cycle must end December 31, 2018.
We will not be able to process this form. In order to be eligible for an extension request, your membership dues must be up to date.

Why were you unable to complete your CEU requirements during your regular four year cycle?*
How has/will your situation changed to allow you to complete your required CEUs within the next year?*
How many CEUs do you need to complete within the next year?*
Please detail your plan for completing the required CEUs. (Where, when, and how?)*
By signing below I affirm that the information I am providing is true and accurate. I acknowledge that I am requesting a one-year extension that is granted only once in a member’s lifetime and cannot be renewed. I understand that I have up to one year to complete the CEU requirement and that this extension does not extend the end date of any future certification cycles.*