Certification Application and Renewal Form

Name

Title

Home Address

City

State

Zip

Home Phone

Cell Phone

Agency's Name

Agency Address

Agency City

Agency State

Agency Zip

Agency Phone Number

Agency Email

Age

Date of Birth

How would you like to pay?

Pay by Credit Card Mail Check

Once this form has been submitted, we will contact you to set up a payment or send an invoice based on your payment selection. Thank you!

CERTIFICATION TERMS AND ACKNOWLEDGEMENT STATEMENT

I understand that my officer certification will be effective for 2 years from the date of renewal. I understand that I must obtain 20 hours of continuing education units (CEUs), and submit to the MACA certification committee, a copy of the training certificates or attendance awards, before the date of certification expiration, to be eligible to future renewal of my MACA certification. In addition to submitting the required continuing education units, I must also pay the certification renewal fee of $20.00, to MACA before the expiration date of my certification. I understand that, while MACA will attempt to keep me informed of my CEU credits and to notify me when it is time to renew my certification, it is my responsibility to keep track of my CEUs and certification expiration dates. By submitting this form you are stating that you understand and agree to these terms.