ACPE Candidate Declaration Page
Candidate's Name
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Please choose one of the following (based on the attached graphic):
*
OPTION 1: Remain in the Old Certification Process
OPTION 2: Transition the New Certification Process
Please read and acknowledge the following:
*
I understand that my decision is final and that I will not be able to change my mind after December 31, 2018
Signature
*
Date
*
-
Month
-
Day
Year
Date
Enter the message as it's shown
*
This form must be returned to Sheilah Hawk in the ACPE office BEFORE December 31, 2018.
Submit
Should be Empty: