Reinstatement

If you do not renew on or before your expiration date you only have 6 months to reinstate by paying the $200 reinstatement fee and doing your CEs. If you fail to reinstate within the 6 months period from the date of your expiration, then you will need to take the exam again. After the $200 reinstatement fee is paid on this page please proceed to the renewal page to pay your renewal fee. The reinstatement fee must be paid in addition to your renewal fee.

Date / Time *

Date

Time

Applicants Name *

First

Last

Date of Birth *

Gender *

Phone *

Applicants Email *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Select Certification you are applying to reinstate *

Certification Number

Has any health-related licensing, certification or disciplinary authority taken adverse action (revoked, annulled, cancelled, suspended, etc.) against you?

- If yes, indicate the type and number of license/certificate:

I have successfully completed eight-hour (8) hours of in-service/continuing education (CE) hours during my most recent certification period (eight (8) hours per every 2 years).

I have provided my skills or allied health-related services in a facility to residents for compensation (under the supervision of a licensed health professional) within my most recent certification period (eight (8) hours per every 2 years).

List current or most recent facility, agency, or organization you are or were employed with. Current Employer:

Employers Address

Address Line 1

Address Line 2

City

State

Zip Code

Employers Phone

Direct Supervisor

I certify, under penalty of perjury under the laws of the State, that the foregoing is true and correct.

Please Upload a copy of your state issued photo ID? *

Click or drag a file to this area to upload.

Reinstatement $200 *

Pay Now *

Card

Name on Card