Practitioner Board Certification Application

Date*

Name*

First

Last

Email*

Confirm Email*

Password*

Confirm Password*

How would you like your name to appear on your wall certificate?*

Birthdate*

Phone*

Address*

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Where should we mail the wall document? If same as above, leave blank.

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Website

Please add “https://” before “www.”

Upload a copy of ALL certificate(s), diploma(s), degree(s), transcript(s), license(s)* **PROOF OF EDUCATION IS REQUIRED!

Compatible Files: jpg, png, pdf, word.

To upload multiple documents, please hold down the "Ctrl" key.

Copy of Driver's License or Passport*

Compatible Files: jpg, png, pdf, word.

Where did you hear about AANWP?*

Message

I testify that all statements and information provided on this form are true & accurate.*

Yes

I understand that laws may vary from country to country & state to state. If I am certified, I will abide by all state regulations.*

Yes

I agree to the AANWP Terms and Conditions.*

Yes

I agree to the AANWP Privacy Policy*

Yes

Board Certification Application for Wellness Practitioners