lnstructions 

  1. This form may be used only for application of Category II PCE credit(s).

  2. Only individual registered technicians required by ABC to satisfy continuing education requirements for maintaining registration may use this form to apply for credit. Please use one form for each activity submitted.

  3. If you are submitting an application for a continuing education activity other than the "type of program or activity" as listed on the front of the application, please provide a brief description of this activity on the line indicated as "other" (i.e., journal readings; colleges courses; teaching clinics; published articles; study groups; etc.).

  4. This application for Category II PCE credit(s) must accompany the Registered Technician Evaluation Form, a copy of the detailed course/brochure, indicating titles of the lectures, names and qualifications of speakers and duration of each lecture must be included along with proof of attendance (certificate or canceled check for payment of registration fee).

  5. Documentation which accompanies this application must be identified with the individual registered technicianís name and registration number at the top of each page.

By submitting this form electronically I verify that I have read and understand the policies and procedures governing the award of Professional Continuing Education credits outlined in the Policies and Procedures manual. Further, I understand that illegible or incomplete applications will cause a delay in processing or may render this application ineligible for credit.

American Board for Certification in Orthotics and Prosthetics, Inc. (ABC)
1650 King Street, Suite 500
Alexandria, VA 22314-2747

When the form has been submitted electronically, a "receipt" will appear on the screen.  Please print a copy of this receipt for your records.   If you choose not to submit electronically, complete the form on-line and print it.   Do not select submit to ABC.  Instead select "Back" on your browser.    Retain a copy of the application for your records and mail the form to:

 

To move from field to field just press the "TAB" key on your keyboard.

 

Important: Refer to instructions above for completing this application. This application must be submitted within 30 days of completion of the course/program or other activity.



Name:
(Last, First, MI)


Certification and Number (indicate CP, CO and CPO)


Address



City

State

Zip

 

 
 

e-mail address

Fax number

 

Indicate the Category II program/activity for which this application is being submitted:


Category


Other - Specify



Date

 

Describe in a paragraph the knowledge you gained from your participation in this activity.