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CAOHC

Application for Certification/Recertification
CAOHC Course Director

Application

Printable form (certification) (PDF file)
Printable form (recertification) (PDF file)

Certification
Recertification

Name (Include Professional Degrees):*
Please indicate your preferred address: Work Home

Work Address

Affiliation/Company: 
Address:
City, State, Zip: ,  
Province/Country

Home Address

Address:
City, State, Zip: ,  

Job Title:
Occupation:

Telephone Number

Work:  Home:  
Fax:     E-Mail:* 
Website (if applicable:    

Professional Information

A.  Indicate your current certification by any of the following certifying boards.


Certification expiration date:
 
B.  Indicate your current membership in any of the following professional organizations:
 
C.  Indicate current professional licensure or registrations, with dates awarded, and upload a copy of current license or registration (or fax to 414/276-2146).
Profession State/Territory Date
File attached:
 
D.  Provide any additional comments which you feel would be helpful to CAOHC in considering your application.


Terms and Conditions

If you are submitting online, you MUST read the following and agree by checking this box BEFORE you submit your application.

* I verify, to the best of my knowledge, that the information provided in this application is true and accurate.

  1. I agree that CAOHC may verify any information provided in this application by contacting listed employers, educational institutions, or clients.
  2. I understand and accept that CAOHC may from time to time impose additional requirements for courses and Course Directors, and that my continued tenure as a Course Director will require my compliance with those requirements.
  3. I understand and accept that although Course Director certification is ordinarily valid for a five-year term, this certification can be revoked for failure to comply with CAOHC requirements, including those enumerated above.

Signature (if submitting by mail or fax):___________________________________________

Date: ____________

Workshop Registration

Saturday, February 2, 2019 - (Military only)
Grapevine, (Dallas) Texas
Wednesday, February 6, 2019 - Military and Civilian course
Grapevine, (Dallas) Texas
I am active Military personnel
DOD ID:
Branch:

Workshop Information

Registration fee due in full (7) seven days in advance of the workshop. Workshop registration fee includes: Continental breakfast, CAOHC Hearing Conservation Manual and all necessary course materials and handouts.

Cancellation Policy
Seven days prior to the workshop, a full refund, with the exception of a $25 processing fee, will be made to any registrant who must cancel his/her attendance. After 7 days prior to the workshop, no refund will be made.

Attendance Policy
Candidates must be present for the entire course in order to be granted certification, recertification, and CEU credits.

Registration Information

Preferred Name on Workshop Badge:

I require special accommodations or specific dietary requirements to fully participate. (Describe needs below.)

How did you hear about the workshop?
CAOHC website CAOHC mailing
OHC course Other:

Payment Information

Recertification Fee: * $125.00
Workshop or Exam Registration: * $0
Total: * $125.00
Payment Type:*
(online orders are payable
by credit card only)
Check
Money Order
MasterCard
Visa
American Express
Name on Card:*
Credit Card Number:*
Expiration Date (MM/YY):*
 

* indicates required field

Submit online or print and fax (credit card orders only) or mail with payment to:

CAOHC
555 E. Wells Street, Suite 1100, Milwaukee, WI 53202-3823
Phone: 414/276-5338    Fax: 414/276-2146      info@caohc.org



FOR OFFICE USE ONLY: 
  Rec'd @ CAOHC Office:

Signature: __________________________________________ Date: ____________