EmailMe Form - Official Application for Emeritus Status

INSTRUCTIONS

To apply for emeritus status, you must submit this form along with the certification fee of $100. Emeritus status is available to ACAC certificants who are no longer active in their fields.

Need Help? Contact our friendly staff at (888) 808-8381 (M-Th 7 to 4, MST) or via email at info@acac.org.

CONTACT INFORMATION

Full Name *

First Last

Primary Email *

Secondary Email

Last 4 Digits of SSN/SIN *

International candidates, please enter 0000

Home Phone *

### - ### - ####

Mobile Phone *

### - ### - ####

Home Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Driver's License (required)

Please upload a photocopy of the your driver's license in PDF, JPG, PNG or GIF format.
Maximum file size: 500 KB

ACAC Certifications Held

Please list the ACAC certification(s) for which emeritus status is requested.

Need Help? Contact our friendly staff at (888) 808-8381 (M-Th 7 to 4, MST) or via email at info@acac.org.

AFFIDAVIT

Please check each box to indicate that you attest to the following statements, then sign below:

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I am no longer active in the field for which ACAC certification was granted.

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I agree to refrain from professional activities related to my ACAC certification.

*

I understand that the application fee is non-refundable.

*

I agree to indemnify and hold harmless the ACAC and all its agents and employees from and against any liability whatsoever in connection with this application and/or the granting of or failure to grant certification.

Signature (please sign with computer mouse or fingertip)

Clear

Unsigned applications will not be accepted.

Submitting your Application and Next Steps

When you click SUBMIT below, your application will be sent to ACAC and copied to your primary email address. Please check the boxes below to indicate that you have read and understand the next steps in the certification process.

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I understand that my response to the verification email is necessary for processing my application.

You will receive an email from ACAC asking for verification that you personally have signed the affidavit above. Please respond to this email in the affirmative to allow us to continue processing your application.

*

I understand that ACAC will invoice me for certification-related fees.

You will receive an invoice from ACAC for emeritus certification fees.