BCCA Recertification Form

Certified Clinical Anaplastologist (CCA) Renewal Application

Renewal Application: The BCCA recognizes that professional development in anaplastology does not end with the passing of a test and awarding of the credential. Practice of Clinical Anaplastology requires the constant renewal of knowledge and experience in the areas of technology, materials science, clinical practice and regulatory compliance as they relate to the field. Renewal is an important part of any respected certification program and it is required to maintain the certification after passing the exam. Renewal helps to ensure the validity and credibility of the BCCA's exam by requiring that individuals holding the designation remain updated and informed about recent developments and advances in the anaplastology industry.
The CCA credential issued by the BCCA is awarded for a term of three years. All expiration dates will be Novemeber 1st regardless of exam date. To remain in good standing, certificants are required to comply with the following renewal criteria:

1. Submission of a completed CCA Renewal Application (Parts A & B)

2. Maintenance of annual renewal fees

3. Accrual of thirty six (36) continuing education units (CEUs) during the three (3) year reporting cycle

4. Upload verification documents for the units submitted.

5. Attestation and compliance with the BCCA Code of Conduct and Administrative Procedures
Part A | Certificant Information

Personal Contact Information
Certification Number
Reporting Cycle
Full Name *

Prefix First Name Last Name Middle Initial
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number *

Area Code Phone Number
Fax

Area Code Phone Number
E-mail *
Business Contact Information
Business Name
Business Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number *

Area Code Phone Number
Fax

Area Code Phone Number
E-mail *
Mailing Address

Business Personal
Phone

Business Personal
Email

Business Personal
Fax

Business Personal N/A
Professional Credentials
Certification 1
Year Awarded
Mandatory CE

Yes No
Sponsor
Upload a File

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Certification 2
Year Awarded
Mandatory CE

Yes No
Sponsor
Upload a File

Cancel of
Certification 3
Year Awarded
Mandatory CE

Yes No
Sponsor
Upload a File

Cancel of
Employment Information
Primary Occupation

Clinical Anaplastologist Ocularist Prosthetics/Orthotics Educator Medical Illustrator Maxillofacial Prosthodontist Administrator Researcher Other
If Other, please specify
Job Title
Part B | Renewal Verification Log

Please refer to the Continuing Education Qualifying Activities Summary
1. Educational Programs
BCCA Category
BCCA Category
BCCA Category
BCCA Category
Please attach corresponding certificate(s)

Upload a File

Cancel of
Subtotal CEUs for Category 1
2. Formal Education/Independent Learning
BCCA Category
BCCA Category
BCCA Category
Please attach corresponding certificate(s)

Upload a File

Cancel of
Subtotal CEUs for Category 2
3. Publication of Material
BCCA Category
BCCA Category
BCCA Category
BCCA Category
BCCA Category
BCCA Category
BCCA Category
BCCA Category
BCCA Category
BCCA Category
Please attach corresponding certificate(s)

Upload a File

Cancel of
Subtotal CEUs for Category 3
4. Instruction/Discussion Leader/Speaker
BCCA Category
BCCA Category
BCCA Category
BCCA Category
BCCA Category
BCCA Category
Please attach corresponding certificate(s)

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Cancel of
Subtotal CEUs for Category 4
5. Volunteer Activities
BCCA Category
BCCA Category
Please attach corresponding certificate(s)

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Cancel of
Subtotal CEUs for Category 5
6. Mentoring/Training Activities
BCCA Category
BCCA Category
BCCA Category
Please attach corresponding certificate(s)

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Cancel of
Subtotal CEUs for Category 6
Certificate Information
Candidates who successfully fulfill their CCA renewal requirements will receice a new certificate; official certificates will be sent within 30 business days of application approval.
Name exactly as it should appear on the certificate *

Suffix First Name Middle Name Last Name
Candidate Responsibility Statements
*

I understand that the CCA Renewal Application must be received on or before my renewal date. I have read and understand all the policies in the Candidate Handbook. I have read and accept the terms and responsibilities outlined in the BCCA Code of Conduct and Administrative Procedures and continuing education standards as set forth by the Board of Directors. I attest that I have never been convicted of, pled guilty or not contest to, a misdemeanor or felony, or any fraud, false statements, or omissions, wrongful taking of property, bribery, perjury, forgery, or a conspiracy to commit any of these offenses. I declare that all the information I have provided on all pages of the CCA Renewal Application is true and accurate. I understand that misrepresentations or incorrect information provided to BCCA can result in disciplinary action(s), including suspension or revocation of my eligibility, examination score, or credential.
Your CEUs
Automatic calculation of the (6) category subtotals
Signature
Date

Month Day Year
Should be Empty:

Certified Clinical Anaplastologist (CCA) Renewal Application

Part A | Certificant Information

Part B | Renewal Verification Log

Certificate Information

Candidate Responsibility Statements