INDEPENDENT OR NON-ARCB® APPROVED STUDY COMPLETION

Upon completion of your pre-approved Independent Study project or Non-ARCB^® Approved activity/course, submit this form for review and approval. Please attach verification of completion for any course or activity you attended. If more than one project/activity was pre-approved on the same form, then be sure to submit your completion form covering all pre-approved activities. If additional space is needed, please submit that information by e-mail or fax to the office. You will be notified whether your completion form is approved following review by the Continuing Education Committee.

Certificant Name

ARCB^® #

Street Address

City

State / Province

Zip / Postal Code

Country

Contact Phone

Email

Enter the course or project title(s) of the activity(ies) completed:

Describe in specific detail what you learned from this project and how you will apply it in your business/practice:

Select the appropriate item and then complete details below.

Independent Study

Non-ARCB^® Approved Study

All statements made herein are true and complete to the best of my knowledge. I understand and agree that misrepresentation or omission will cause forfeiture of any CE hours that may be approved from this application.

My 2-year period ends December 31 of

You can determine your 2-year period by looking at your ARCB ^®certification document. The cycle begins January 1 of the year after you achieved certification and ends 2 years later on December 31st and every 2 years thereafter. If you’re still not sure, call the office to verify.

Birth Date

ELECTRONIC SIGNATURE *

Type your name or initials into the box below.

American Reflexology Certification Board ®

INDEPENDENT OR NON-ARCB^® APPROVED STUDY COMPLETION

ELECTRONIC SIGNATURE *