Application for Recertification - JCAHPO

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1ApplicantYour name will appear on your certificate as written for Recertification14PaymentName: of Birth: (mm/dd/yy) ______/______/__________________________ ________________________________________ ______________________________________(_ _______________________)FirstMiddleLastS uffixFormer name (if applicable)Home Address: ________________________________________ ________________________________________ ____________________________Apt. #_______________________________________ ________________________________________ ________________________________________ ____CityStateZip CodeCountryTelephone: (________)________________________ (________)________________________ Preferred E-mail_________________________________H omeWorkSECTION A (for COA, COT, COMT, Ophthalmic Surgical Assisting, ROUB, and CDOS applicants)Clinic Name:___________________________________ ________________________________________ ________________________________________ ___________Main Clinic Address:________________________________ ______

•Recertification fee is $125. ($50 of which is a non-refundable processing fee for cancelled applications. No refunds will be issued for denied applications.) •If your recertification application is postmarked within the 12 months after your recertification date you will need to include an $85 late fee.

  Applications, Recertification, Recertification application