CHLCP® Portfolio Examination Application CHLCP Initial Certification ExamThis form is for the collection of all required data for the initial certification of a candidate for the CHLCP certification.Step 1 of 714%EmailThis field is for validation purposes and should be left unchanged.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.TitleTitle (e.g., Ms, Mrs, Mr, Dr, etc.First Name(Required)Middle InitialLast 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 / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Work AddressOptional Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Please provide at least one phone number below.Work PhoneHome PhoneCell PhonePlease select your preferred phone for communications.(Required)HomeWorkCellADA Information. Are you requesting test accommodations and have a disability covered by the Americans with Disabilities Act? Select an option.YesNoPlease be sure to choose the answer that is a specific to you.Have you taken this examination before?(Required)YesNoDate of Examination (only month and year are required) MM slash DD slash YYYY Are you currently, or have you ever been certified as a CHLCP™(Required)YesNoWhen Does/Did your certification expire? MM slash DD slash YYYY 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)YesNoA Candidate must have an unrestricted healthcare license that has been valid a minimum of two years.Type of LicensePlease choose the license type that is current to the area of which you are currently practicing within.Medical/Osteopathic DoctorNurse PractitionerOccupational TherapistPhysical TherapistPsychologist/NeuropsychologistRegistered NurseSpeech TherapistChiropractorLicensed Social WorkerOtherLicense #(Required)Please provide us with your healthcare license number: *State where licensed" *(Required)AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificLast Issue Year?When does your license expire? MM slash DD slash YYYY Please complete the required fields.Highest academic level attained *(Required)Associate DegreeDiploma in NursingBachelor's Degree, NursingBachelor's Degree, Non-nursingMaster's Degree, NursingMaster's Degree, Non-nursingDoctoral DegreeDoctoral Degree, Non-nursingEducation/Skills* (Select One)(Required)Option 1 (120 hours of continuing education units as outlined in the Handbook)Option 2 (2 years/4000 hours pain or billable life care planning experience as outlined in the Handbook)What percentage of your time is spent in working in life care planning?0-24%25-49%50-74%75-100%Number of years in Case Management0-2 years3 years4-5 years6-7 years8-9 years10 or more yearsNumber of years in Life Care Planning *(Required)0-2 years3 to 4 years5 to 6 years7 to 10 yearsOver 10 yearsSelect your primary practice settingIndependent PracticeInsuranceLaw FirmCase Management CompanyGovernment AgencyManaged Care OrganizationIntegrated NetworkHospitalOtherOtherIf you chose other from the above question, please be sure to provide your answer here.Organizations to which you belong:(Please check all that apply) American Academy of Physician Life Care Planners American Association of Legal Nurse Consultants American Association of Nurse Life Care Planners (AANLCP) American Nurses Association Association of Rehabilitation Nurses Case Management Society of America International Association of Rehabilitation Professionals/International Academy of Life Care Planners National Association of Case Managers National Medicare Secondary Payer NetworkSelect AllHow did you hear about this examination: *(Required) Conference Professional Journal Employer Colleague / word of mouth Social Media Internet OtherAre you currently a member of AANLCP?(Required)NOTE: AANLCP membership is not required.NoYesPlease provide your AANLCP Membership NumberSupporting 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 Select filesAccepted file types: pdf, Max. file size: 1 GB.Candidate Statement and SignatureI 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 statementsPlease choose correct testing fee schedule(Required)Your selection will determine the correct price that is charged to your billing card of choice. Initial Application $395.00 Retesting Fee (Failed Testing) $245.00 CHLCP Renewal by Portfolio Exam $395.00 Late Renewal by Portfolio Exam (Within 30 Days of Expiration) $595.00Option1Initial Examination $395.00 Price: Option2Re-testing Fee (Failed Testing) $245.00 Price: Option3CHLCP Renewal by Portfolio Exam $395.00 Price: Option4Late Renewal by Portfolio Exam (Within 30 Days of Expiration) $595.00 Price: Credit CardTotal 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.Δ