Application for Recertification - JCAHPO

1 ApplicantYour name will appear on your certificate as written for Recertification14 PaymentName: of Birth: (mm/dd/yy) _____/_____/_____(_____)FirstMiddleLastS uffixFormer name (if applicable)Home Address: _____Apt. #_____CityStateZip CodeCountryTelephone: (_____)_____ (_____)_____ Preferred E-mail_____HomeWorkSECTION A (for COA, COT, COMT, Ophthalmic Surgical Assisting, ROUB, and CDOS applicants)Clinic Name:_____Main Clinic Address:_____City: _____State:_____Zip: Telephone: _____FAX:Clinic Manager: _____ _____ s Practice Setting(Check all that apply) oPrivate, Solo oPrivate, Group: Number of Physicians o2-5 o6-10 o11 or moreoHospital Clinic or HMOoUniversity ClinicoOther.

•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.

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  Applications, Recertification, Recertification application

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