CNLCP® Re-Certification ApplicationCertified Nurse Life Care Planner (CNLCP®) Recertification by Continuing EducationStep 1 of 812%To recertify by exam, please complete the initial application for certification. This application is for Certified Nurse Life Care Planners who wish to recertify by continuing education.When filling out the application, please enter all requested information in the spaces provided or select an option using the menus. If your examination requires supporting documentation, you can upload electronic files in the Supporting Documentation section of the application. Supporting documents must be in PDF or JPG prior to uploading. Be sure to save your application by selecting the Save Application button at the bottom before submitting your application to the Universal Life Care Planner Certification Board (ULCPCB™).Candidate Information Ms. Mrs. Mr. Dr.First Name(Required)Middle Name (optional)Last Name(Required)Email Address: Please enter a valid email address. Please add shirley@daugherty-legalnurse.com to the safe domain list of your email to ensure that emails from ULCPCB™ are received.Email(Required) Enter Email Confirm Email Address(Required) Street Address Address Line 2 City 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 Pacific State ZIP Code Work/Business Address (optional) Street Address Address Line 2 City 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 Pacific State ZIP Code Work PhoneHome PhoneCell PhonePlease select your preferred phone for communications(Required) Home Phone Cell Phone Work PhonePlease select your preferred address for mail communications.(Required)Please note: If you chose the “Work/Business” option, please ensure that you have filled the appropriate address information in the box above. Home Work/BusinessRN License Number(Required)License State(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 Pacific State When does your license expire?(Required) MM slash DD slash YYYY Current Certification Date(Required) MM slash DD slash YYYY Current Certification Number:(Required)Are you currently a member of AANLCP?(AANLCP membership is not required) No YesAANLCP Membership Number:Are you willing to share your name, address, telephone number and email address with AANLCP?(Required) No YesSelect the organization to which you belong:(Required)Please select all that may apply to you. American Association of Nurse Life Care Planners (AANLCP) American Association of Legal Nurse Consultants American Nurses Association Association of Rehabilitation Nurses Case Management Association of America International Association of Rehabilitation Professionals/International Academy of Life Care Planners National Institute of Case Managers OtherIf you chose “Other” from the above question, please list it here.You must provide documentation of continuing education. You are required to complete 60 CEUs within appropriate course content in the last five-year period beginning from the date of your initial certification or recertification. You must maintain an unrestricted, current RN license throughout the five-year certification period. Refer to recertification guidelines listed in the CNLCP® Handbook for Candidates for appropriate course content and for alternatives to continuing education. You must upload certificates of completion with this application. Please note that proof of attendance and/or copies of certificates should be kept by you for a minimum of five years. Your documentation is subject to audit by the certification board.Please create a separate document to list your continuing education contacts. Each item must include: Date and name of course, Contact Name & Contact Number, Address of CEU, Number of Hours, ProviderUpload Your Documentation of Continuing Education Here(Required) Drop files here or Select filesAccepted file types: docx, doc, pdf, jpg, Max. file size: 1 GB.All of the following documents must be provided with this application. Failing to do so, will delay the completion of it. Please include a copy of your current Rn License and Proof of Attendance and/or Copiess of Certificate of Completion.Upload your RN License & Proof of Attendance and Copies of Certificate of Completion Here(Required) Drop files here or Select filesAccepted file types: docx, doc, jpg, pdf, Max. file size: 1 GB.Candidate Statement of Fact(Required)* I have read the recertification guidelines for Candidates and understand I am responsible for knowing its contents. I certify that the information given in this Application is in accordance with recertification guidelines instructions and is accurate, correct, and complete. Information of a candidate's initial certification date, renewal dates, and any CNLCP® suspensions or revocation of CNLCP® will be released by the Universal Life Care Planner Certification Board (ULCPCB™) upon requests 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 nurse life care planners. Additional personal information will not be released without my approval. By checking this box, I certify all of the above statements. I Acknowledge The Above StatementInput Your Legal Signature(Required)By inputting your signature here, you are acknowledging it as your legal signature.+++++++++++++++NOT FOR THIS APPLICATION BUT FYI Recertification by exam, AANLCP member: $425-THEY NEED TO USE INITIAL APPLICATION IF TESTING BY EXAM TO RENEW Recertification by exam, non-AANLCP member: $525-THEY NEED TO USE INITIAL APPLICATION IF TESTING BY EXAM TO RENWCNLCP® Recertification Fees:(Required)Please select the option that applies to you to ensure the correct billing amount is reflected for your payment. Recertification by points/CEUs, AANLCP Association member $375 Recertification by points/CEUs, non-AANLCP member $475 Late Recertification, AANLCP Association Member: $575 Late Recertification, non-member AANLCP: $675.00Recertification by points/CEUs, AANLCP Association member $375 Price: Recertification by points/CEUs, non-AANLCP member $475 Price: Late Recertification, AANLCP Association Member: $575 Price: Late Recertification, non-member AANLCP: $675.00 Price: Please Provide Your AANLCP Membership IDConsent(Required)By checking here, you are agreeing to allow us to post your name, email address, and date of initial certification/expiration on the ULCPCB™ website for its online listing of current certified nurse life care planners. I agree to the listing policy as a part of my re-certification on the ULCPCB website.Credit CardAmerican ExpressDiscoverMasterCardVisaSupported Credit Cards: American Express, Discover, MasterCard, Visa Card Number Expiration Date Month Month010203040506070809101112 Year Year20242025202620272028202920302031203220332034203520362037203820392040204120422043 Security Code Cardholder Name Total Δ