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CAOHC

Application for Recertification
CAOHC Course Director

Recertification Application

Printable form (PDF file)

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.
 
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: ____________

Recertification Application Options

Option 1: Complete the eight-hour CAOHC CD training workshop. Complete the on-line examination with a passing score of 80% or higher.
Option 2. Complete the on-line examination with a passing score of 80% or higher.

AND

Fulfill at least two of the following items during the application's five year credential term:
1. Serve as CD for a minimum of 10 OHC courses with no substantiated violations of CAOHC policies and procedures.
2. Actively participate on a CAOHC committee or task force for at least two full years. Active participation means attendance at scheduled conference calls and contribution to committee projects.
3. Submit and have accepted for publication, a minimum of two articles in CAOHC's newsletter Update.
4. Accrue a minimum of 10 continuing education contact hours related to Occupational Hearing Conservation
5. Participate as an approved instructor in one or more CAOHC sponsored CD workshops.

Payment Information

Recertification Fee: * $125
Workshop or Exam Registration: * $0
Total: * $125
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: ____________