2013 AIMVT RECERTIFICATION APPLICATION

Initial Certification Date: __________________________________

Recertification Date: _____________________________________

Name (Last, First, MI) ____________________________________

Street Address _________________________________________

City ____________________________________________________

State ___________________________________________________

Zip or Postal Code ________________________________________

Country _________________________________________________

Phone Number ___________________________________________

Email Address ____________________________________________

Current Employer's Busines Name ___________________________

Street Address ___________________________________________

City____________________________________________________

State___________________________________________________

Zip or Postal Code_________________________________________

Country_________________________________________________

Are you currently credentialed to legally practice in your state or province? Yes ( ) No ( )

Enclose a copy of your current license ( )

Choice of recertification route - Examination ( ) Continuing Education ( ) Relinquish ( )