A Test Page - Universal Life Care Planner Certification Board

Please read the Handbook for Candidates carefully before completing this application. When filling out the application, please enter all requested information in the spaces provided. Please include all supporting documentation with your application. There are a total of 9 sections that this form will ask you to complete.Please note, Candidates applying under Option 2 must provide verification indicative of two (2) years full time, paid, professional work experience in the field of life care planning or a variant thereof as outlined in the Handbook. A completed Verification of Work Experience form must be included with supporting documentation and can be located here.

Please enter your name exactly as it appears on your Government-issued photo I.D.

Title(Required)

Title (e.g., Ms, Mrs, Mr, Dr, etc.

First Name(Required)

Middle Initial

Last Name(Required)

Please add secretary@ulcpcb.org to your safe domain list in your email client to ensure that emails from the Universal Life Care Planner Certification Board™ are received.

Email

Enter Email Confirm Email

Home Address(Required)

Street Address Address Line 2 City State ZIP Code

Work Address

Optional

Street Address Address Line 2 City State ZIP Code

Please provide at least one phone number below.

Work Phone

Home Phone

Cell Phone

Please select your preferred phone for communications.(Required)

ADA Information. Are you requesting test accommodations and have a disability covered by the Americans with Disabilities Act? Select an option.

Please be sure to choose the answer that is a specific to you.

Have you taken this examination before?(Required)

Date of Examination (only month and year are required)

Are you currently, or have you ever been certified as a CHLCP™(Required)

When Does/Did your certification expire?

What is your most recent certification number? ( Only * if you are applying to recertify your CHLCP™ credential)

Please be sure to complete all required fields.

Do you have a current, unrestricted healthcare license that has been valid a minimum of two years?(Required)

A Candidate must have an unrestricted healthcare license that has been valid a minimum of two years.

Type of License

Please choose the license type that is current to the area of which you are currently practicing within.

License #(Required)

Please provide us with your healthcare license number: *

State where licensed" *(Required)

Last Issue Year?

When does your license expire?

Supporting Applicant Documentation(Required)

All of the following documents must be provided with this application.

Copy of current healthcare license

Copy of current resume or curriculum vitae

Candidates applying under Option 1 only (Proof of 120 hours of continuing education as outlined in the Handbook)

Candidates applying under Option 2 only (Completed Verification of Work Experience Form)

Completed Request for Test Accommodations Form (if applicable)

To upload your supporting documentation, please ensure that your documents are either in PDF or JPG formats. Click on the "Browse" button and select your files from the drive or folder where you have your documents saved. Then click on "Upload Files". You can upload multiple files at one time to make the submission process easier. Your files cannot exceed a total of 6mb in size.

Select Files(Required)

Drop files here or

Accepted file types: jpg, pdf, doc, docx, Max. file size: 1 GB.

Candidate Statement and Signature

I have read the Handbook for Candidates and understand I am responsible for knowing its contents. I certify that the information given in this Application is in accordance with the Handbook instructions and is accurate, correct, and complete. Information of a Candidate's initial certification date, renewal dates, and any CHLCP™ suspensions or revocation of CHLCP™ will be released by the Universal Life Care Planner Certification Board (ULCPCB™) upon request to any public entity or agency. Verification is also available via the website tool. By signing this Application, I am providing authorization for release of this information and for the use of aggregate data. I additionally authorize the ULCPCB™ to post my name, email address, date of my initial certification and expiration date on the ULCPCB™ website for its online listing of current certified health professional life care planners. Additional information will NOT be released without my approval.I have completed a minimum of two (2) years 4000 hours paid or billable professional healthcare experience that requires licensure and documentation of Patient/Client needs within the five (5) years immediately preceding this application.

Electronic Agreement(Required)

By checking this box I certify all of the above statements

Initial Examination

Price:

Credit Card

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

Total

By checking this box you are providing this as an authorized electronic signature to file this application.(Required)

By checking this box is the same as my electronic signature of my name to comply with the submission of this application as though I had done so in person.

Phone

This field is for validation purposes and should be left unchanged.

Universal Life Care Planner Certification Board

Candidate Statement and Signature

CHLCP™Education Resources

FAQ

About Us

Position Statements

Our Blog

CNLCP® Certification Fees

CHLCP™ Certification Fees

CHLCP™ Certification Application

CNLCP® Verification of Work Experience

CHLCP™ Verification of Work Experience

CNLCP® Recertification Guidelines and Application

Request for Testing Accomodations