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Get Certification Maintenance Compliance Form Asha

CERTIFICATION MAINTENANCE COMPLIANCE FORM Instructions Print this form Complete all information Sign at the bottom Submit your form via mail or fax ASHA 2200 Research Blvd. 313 Rockville Maryland 20850 301-296-8569 Please provide current accurate information Check here if this is a new address Compliance Interval Check area s of certification ASHA ID CCC-A Name CCC-SLP Dual Previous Name s Used Address Street Daytime Phone City State Zip Evening Phone E-mail Affidavits Your signature on this form affirms that you have read the following statements and agree to abide by each statement 1. I affirm that the information provided on this Compliance form is accurate. 2. I affirm that in accordance with the Certification Standards I have participated in 30 Certification Maintenance Hours of professional development during my 3-year certification maintenance interval. 3. 313 Rockville Maryland 20850 301-296-8569 Please provide current accurate information Check here if this is a new address Compliance Interval Check area s of certification ASHA ID CCC-A Name CCC-SLP Dual Previous Name s Used Address Street Daytime Phone City State Zip Evening Phone E-mail Affidavits Your signature on this form affirms that you have read the following statements and agree to abide by each statement 1. I affirm that the information provided on this Compliance form is accurate. 2. I affirm that in accordance with the Certification Standards I have participated in 30 Certification Maintenance Hours of professional development during my 3-year certification maintenance interval* 3. I affirm that I abide by the Code of Ethics of the American Speech-Language-Hearing Association* certification fees upon my receipt of the annual invoice. standard and payment of the annual certification fees I will cease using the designation CCC-A and/or CCC-SLP and will not display the Certificate of Clinical Competence. I affirm that the information provided on this Compliance form is accurate. 2. I affirm that in accordance with the Certification Standards I have participated in 30 Certification Maintenance Hours of professional development during my 3-year certification maintenance interval* 3. I affirm that I abide by the Code of Ethics of the American Speech-Language-Hearing Association* certification fees upon my receipt of the annual invoice. I affirm that I abide by the Code of Ethics of the American Speech-Language-Hearing Association* certification fees upon my receipt of the annual invoice. standard and payment of the annual certification fees I will cease using the designation CCC-A and/or CCC-SLP and will not display the Certificate of Clinical Competence. I affirm that the information provided on this Compliance form is accurate. 2. I affirm that in accordance with the Certification Standards I have participated in 30 Certification Maintenance Hours of professional development during my 3-year certification maintenance interval* 3. I affirm that I abide by the Code of Ethics of the American Speech-Language-Hearing Association* certification fees upon my receipt of the annual invoice. standard and payment of the annual certification fees I will cease using the designation CCC-A and/or CCC-SLP and will not display the Certificate of Clinical Competence.

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