NCCSA » Recertification Application

Notice

Only use this form if you are NOT a member of the National Surgical Assistant Association (NSAA) and desire to recertify by CEU Submission
Full payment must be submitted along with all CEUs 60 days prior to recertification date
If you prefer to recertify by examination, please click here to schedule your exam
If you are a Current Member of NSAA, please update your contact information in the Member's Area of the NSAA website

We would love to hear from you! Please fill out this form and we will get in touch with you shortly.

Required Documents
Please submit your form with the following required documents by uploading them below.
CEU Documents*
Accepted file types: pdf, Max. file size: 64 MB.
Please compile all CEU documents in a single PDF and upload it here.
Information
Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*
Enter Email Confirm Email
Fax
Current Employer
Employer/Company Name*
Employer/Company Address*
Street Address Address Line 2 City State ZIP Code
Employer Phone
Employer Fax
How Long Have You Been Assisting?*
How Long Have You Been Employed At This Job?*
Immediate Supervisor
Supervisor's Phone
Education and Training
*
Name of Program Location of Program Dates Attended Degree/Certificates Awarded
Previous Employment
Position Held
Date Position Held
Employer/Company Name
Employer/Company Address
Street Address Address Line 2 City State ZIP Code
Employer/Company Phone Number
Direct Surpervisor
Fees
The following fees are associated with your application. Certification application fees are non-refundable.
Recertification Fee*
Price:
Credit Card*

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name
Billing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Total
$0.00
Your card will be charged this amount.
Rules and Regulations*
- I agree
By submitting this form you agree to the rules and regulations and the Ethical Standards of the NCCSA.
Payment Policy Agreement*
- I agree
You are bound by the payment policy of the NCCSA.

Submit via MAIL Instructions

If you would like to submit your payment via MAIL, fill it out the form first, DO NOT CLICK SUBMIT when you are done, and go to File > Print to print what you've filled out. You can them mail in the printout to 1775 Eye Street, NW, Suite 1150, Washington, DC 20006.

Name of Program	Location of Program	Dates Attended	Degree/Certificates Awarded

Recertification Application

Required Documents

Information

Current Employer

Education and Training

Previous Employment

Fees