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Allied Requirement Form

This document is a proof of eligibility form for certification by American Allied Health. It provides instructions for applicants to select which form of documentation they will submit as proof of eligibility to sit for the certification exam - including proof of graduation from a vocational training program, one year of work experience in the field, or applying for certification by reciprocity. It outlines the requirements for each option and contact information to submit the completed form and supporting documentation.

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Kerry Henry
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© © All Rights Reserved
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Download as PDF, TXT or read online on Scribd
98 views

Allied Requirement Form

This document is a proof of eligibility form for certification by American Allied Health. It provides instructions for applicants to select which form of documentation they will submit as proof of eligibility to sit for the certification exam - including proof of graduation from a vocational training program, one year of work experience in the field, or applying for certification by reciprocity. It outlines the requirements for each option and contact information to submit the completed form and supporting documentation.

Uploaded by

Kerry Henry
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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American Allied Health, P.O.

Box 1487, Lowell, AR 72745, (479)-553-7614

Proof  of  Eligibility  Form  


 
Member  Name:  ______________________________  
 
Certification  Number:  ________________________  
 
Directions:  (1)  Select  which  form  of  documentation  you  wish  to  submit  as  proof  of  eligibility  
to  sit  for  the  American  Allied  Health  certification  exam,  (2)  comply  with  the  directions  given  
in  either  option  a,  b,  or  c,  and  (3)  mail  or  fax  in  this  form  to  American  Allied  Health.    
 
Check  ONE  of  the  boxes  below:  
[    ]    (a)  Proof  of  graduation  from  vocational  training  program,  or  military  training.    
[    ]    (b)  Proof  of  one  year  of  work  experience  in  the  field.    
[    ]    (c)  Apply  for  certification  by  reciprocity.      
 
Option  (a):  Mail  or  fax  this  form  along  with  a  copy  of  your  proof  of  training  (e.g.,  certificate  
of  training,  diploma)  to  the  contact  information  at  the  bottom  of  this  page.    
 
Option  (b):  Have  your  employer  or  supervisor  fill  out  the  following  information:  
 
“I  (supervisor’s  name)  ______________________  certify  that  (AAH  member’s  name)  
_______________________  has  been  employed  as  an  allied  heath  professional  with  at  
least  one  year  of  work  experience  in  the  field.”  
Supervisor’s  Name:  ___________________________  
Supervisor’s  Signature:  ________________________  
Supervisor’s  Phone:  ___________________________  
 
Option  (c):  If  you  have  previously  been  certified  with  another  certification  organization  
within  the  last  five  years,  submit  the  following  information:  
 
Previous  Certification  Organization:  ____________________________  
Certification  Number:  ________________________________________  
Certification  Expiration:  ______________________________________    

American Allied Health


P.O. Box 1487
Lowell, AR 72745
Ph: (479) 553-7614
Fax: (479) 553-7285

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