CEU Certificate of Completion Order Form

ANA CEU Certificate of Completion Request Form

This form is for participants who seek to order duplicates of prior Continuing Education Certificates of Completion. Please specify in your request the event date needed. Certificates from the same event/date may be ordered using this form. If seeking certificate copies for multiple dates/different events, a separate entry form will be required for each separate event.

Name *

First

Last

Email *

Phone *

Please provide your IL or NM DN License number

IL licenses 181-000-XXX. License numbers are used to verify active membership. Renew your ANA membership today.

DN License Number *

If you once had a license number and it is inactive, you may write that here. Or you may write 9999 if you are not a licensed DN.

Certificate of Completion Submission

Participants may receive their certificates of completion 1 of 2 ways. Please specify how you would like your certificate given. There is a an additional fee ($10) to re-email or re-print a previously issued CEU certificate of completion.

How would you like your duplicate Certificate of Completion to be provided *

I would like my duplicate Certificate of Completion Printed & Mailed to address I provided here
I would like my duplicate Certificate of Completion Emailed to the email address I provided here

Mailing Address

Address Line 1

Address Line 2

City

State

Zip Code

Please provide your mailing address if you have selected printed certificates to be mailed to you

Renew today at www.naprapath.org/membership

Provide the Event Name or Date for you certificate

Please specify in your request the event date needed. Certificates from the same event/date may be ordered using this form. If seeking certificate copies for multiple dates/different events, a separate entry form will be required for each separate event.

Tell us the event name or date *

Initial Duplicate Certificate of Completion *

Initial Duplicate Certificate of Completion – $ 10.00

Additional Copies

I would like an additional copy – $ 5.00
I would like 2 additional copies – $ 10.00

Print my credentials or license number on my Completion Certificate(s) – OPTIONAL

I would like my credentials AND license number printed on certificate – $ 5.00
I would like my credentials printed on certificate – $ 2.50
I would like my license number(s) printed on certificate – $ 2.50

Printed license numbers are limited to 2 (including DN license number)

Total

$ 0.00

Credentials (Optional) *

If selected from above. Please provide your name and credentials (including DN degree) as they should be displayed on your certificate. Please limit credentials to up to 2 actual degrees awarded, space is limited. Type N/A if not applicable to you.

Other License Info (Optional) *

If selected from above. Please provide your license type and number to be displayed. Printed license numbers are limited to 2 (including DN license number). Type N/A if not applicable to you.

Signature *

Date *

Square *

Card

Name on Card