Certification Application
Members applying for certification must do so on the official application form approved by the Board of Directors for the current year or by completing the online form. The completed application, all required documentation and the non-refundable fellow application fee must be submitted at the same time. Once the application has been accepted. The member may schedule their exam.
Certification Selection
Certified Restorative Medicine Advanced Practice Provider (CRMAP)
Certified Restorative Medicine Nurse (CRMN)
Certified Restorative Medicine Technologist (CRMT)
Date of Application
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Month
-
Day
Year
Date
Personal Information
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Name as you want it to appear on your certificate.
Education Information (If Applicable)
Institution
Graduation Year
Degree Awarded
Please provide proof of graduation (diploma/transcript).
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Employment Information
Current Employer (RM Practice)
Employer Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Dates of Employment
Individual Criteria Information
Years of experience providing direct care to restorative medicine patients.
Training/Licensing Requirement
For Advance Practice Providers: I possess an active certification from accrediting organization and licensures as appropriate for my level (PA-C, FNP-C, etc.).
For Nurses: I possess an active, unencumbered nursing license (RN or LPN) in the state I practice.
For other Allied Health Professionals: I have completed 40 hours of in-service training, 16 of which were be directly related to the practice of Restorative Medicine.
Evidence for Satisfaction of Individual Criteria
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(Resume/CV, License, and/or Training Certificates)
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Attestation
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