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*

PrefixFirst NameLast NameMiddle Initial
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
Fax

Area CodePhone Number
E-mail*
Business Contact Information
Business Name
Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
Fax

Area CodePhone Number
E-mail*
Mailing Address

BusinessPersonal
Phone

BusinessPersonal
Email

BusinessPersonal
Fax

BusinessPersonalN/A
Professional Credentials
Certification 1
Year Awarded
Mandatory CE

YesNo
Sponsor
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Certification 2
Year Awarded
Mandatory CE

YesNo
Sponsor
Upload a File

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Certification 3
Year Awarded
Mandatory CE

YesNo
Sponsor
Upload a File

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Employment Information
Primary Occupation

Clinical AnaplastologistOcularistProsthetics/OrthoticsEducatorMedical IllustratorMaxillofacial ProsthodontistAdministratorResearcherOther
If Other, please specify
Job Title
Proof of recertification of CPR course for Healthcare Providers *

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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)

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

Upload a File

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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)

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

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

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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*

SuffixFirst NameMiddle NameLast 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

MonthDayYear
Should be Empty:

Certified Clinical Anaplastologist (CCA) Renewal Application

Part A | Certificant Information

Part B | Renewal Verification Log

Certificate Information

Candidate Responsibility Statements