Appeal Form
Date
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Month
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Your Name
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First Name
Last Name
Email Address
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example@example.com
Phone Number
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Please enter a valid phone number.
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Please select the purpose of your appeal.
Please Select
Exam Eligibility
Recertification Status
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Please select the date you received the eligibility decicison you are appealing.
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Month
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Please submit appeal letter including the original notification from NCHEC. Appeal letter should identify the adverse decision being appealed and explicitly state the reasons for appeal:
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Please upload a copy of supporting documentation to appeal eligibility (e.g. course syllabi, academic transcript, etc.)
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Upload supporting documents as needed.
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State your Certification number
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Upload an official letter requesting an appeal for third-year extension addressed to the Division Board for Professional Development (DBPD), including a detailed plan of how you will meet the recertification requirements in your third-extension year. Please note: The two extensions previously used will be reviewed by DBPD along with this appeal.
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Please attach supporting documentation of any Continuing Education Contact Hour (CECH) credits that were completed within your current cycle period. Please refer to the Handbook for Renewal and Recertification linked below for guidance.
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Upload supporting documents as needed. Medical forms NOT REQUIRED.
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Handbook for Renewal and Recertification
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Appeals Policy
By completing this form and including my signature below, I am acknowledging that I have read and understood the NCHEC Appeals Policy (linked above and available on NCHEC's website) and that my appeal will not be considered if my submission is incomplete and the appeal fee has not been paid to the NCHEC office.
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