CERTIFICATION RENEWAL REQUEST FORM
(STEP 1)
We renew the highest level certification you currently have. For example, if you already hold a Licensed Practitioner AND Licensed Master Practitioner certification, we will renew the Licensed Master Practitioner certification when it comes due. If you are a Licensed Trainer, we will renew that, and not your Practitioner or Master Practitioner license and certification. If there is a reason that you require a lower certification renewal as well, please make a note about that in the "notes" section. Please keep the note short.
Name:
 (first) * Required
(last) * Required
Address:
 * Required
City:
 * Required
State/Prov:
* Required
Postal Code:
 * Required
Country:
 * Required
E-Mail:
 * Required We ask you NOT to use any apple email addresses (.icloud, .me, etc. until further notice as they have a problem with our domain regardless of whatever we have done to have them correct this.
Phone/Fax:
 (phone) * Required
(fax)
Certification Level:
 * Required
Notes
Miscellanious Info:
If Available,
Enter the Serial # On Your
Official Society Seal:

Institute You Trained with:

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