ip license application2018-10-17T15:16:43+00:00

Congratulations on choosing to become a Licensed CHEK Professional!

If you work for someone who has a CHEK Professional Facility License or CHEK Medical Facility License, do not fill out the form below. Instead, please have the facility owner contact us with your information and verification of employment so that we may send you to the proper form.

To complete your application, please fill out the form below completely. When you submit your completed form, you will be re-directed to a page where you can pay your licensing fee. Paying your licensing fee will complete the application process.

Information on Courses / Seminars for PDCs

List each course/seminar/PDC item you will use to meet your PDC requirement in the box below. You can find more details about PDCs on page 8 of the Licensing Program Guidelines.

You can list multiple courses/seminars/PDC items in this box.

 For each, please enter the following information in the box: 

  1. The course/seminar/PDC item name
  2. Date completed
  3. Provider/Organization
  4. PDC value (1 PDC per contact hour)

Then add up the number of all PDCs and enter this in the lowest box.

CPR & Liability Insurance
 
If you are not actively seeing clients, you are exempt. Please check the appropriate box below. 
 
-OR- If you are actively seeing clients, please complete both CPR and Liability Insurance questions.

Important - Terms of Renewal

I accept and agree to adhere to the C.H.E.K Institute Code of Conduct. I hereby certify that the information contained on this License Application Form and PDC Checklist is true, complete and correct.

Digitally signing this form with your full name signifies that everything you have stated on this form is true and accurate. In addition, you have documentation to support your claim and are able to furnish a copy of that documentation to the C.H.E.K Institute if requested. The C.H.E.K Institute reserves the right to audit License applications at random to ensure compliance.