| MENU |

Professional Supervisor of the Audiometric Monitoring Program Recertification Workshop and/or Exam Registration

First Name:*
Last Name:*
(PhD, MD, DO, AuD)
Job Title:

Please indicate your preferred address:* Work Home
Work Address
City, State, Zip: ,  
Work Phone:*

Home Address
City, State, Zip: ,  


Home Phone:
Cell Phone:

Indicate any current professional license or registrations, with dates awarded.
Profession State/Territory Date Awarded
Attach copy of your current state licensure or registration:*

Upload your current job description or describe your current duties related to occupational hearing conservation or work related determinations for noise induced hearing loss.

* I verify, to the best of my knowledge, that the information provided in this application is true and accurate. As a condition of CAOHC's consideration of my application to become a CAOHC-approved Professional Supervisor, I agree to the following conditions:

  1. I agree that CAOHC may verify any information provided in this application.

  2. I understand that I must continuously hold licensure as a physician or audiologist for the duration of the certification in order to retain CAOHC certification as a Professional Supervisor of the Audiometric Monitoring Program (CPS/A). CPS/A certification is five years.

Recertification Exam Only Registration
I wish to register for the exam only - May 3 - June 3, 2019
Payment Information  

Amount Enclosed*

Payment Type:*
(online orders are payable
by credit card only)
Money Order
American Express
Name on Card:*
Credit Card Number:*
Expiration Date (MM/YY):*

* indicates required field


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