Application for Certification

Certification Course
---

Certification provides you with the opportunity to be listed in the referral network of certified providers. It does not license you to practice.

General information

Name

Mailing Address

City/State/Zip/Country

Phone

Email Address

Professional information

I attest to the following

I am a health provider licensed to practice in my state(s).
I certify that I passed the certification exam at 75% minimum.

Type of license(s)

License #

State(s)

Choose a scanned license file...
Choose a course certificate file...

*This certification does not warrant that this program or its examination certifies a candidate’s competence. Nothing about this program or its examination is intended to replace, override, or conflict with licensing requirements for health professionals and their requirements for practice in their state of residency and practice.

I have read and agree with the above statements and attest that my replies are truthful.
Please add me to the online referral network.