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ACSM RECERTIFICATION / RENEWAL FORM

Please make any corrections in your name and/or address in the section below. Complete the form by providing the additional information to the best of your knowledge. ACSM credentials available for recertification are:

ACSM Certified Personal Trainer (CPT)
ACSM Group Exercise Leader® (GEL)
ACSM Exercise Test Technologist® (ETT)
ACSM Exercise Specialist® (ES)
ACSM Health/Fitness Instructor® (H/FI)
ACSM Registered Clinical Exercise Physiologist® (RCEP)
ACSM Program DirectorSM (PD)
ACSM Health/Fitness Director® (H/FD)

* Denotes manadatory fields

ACSM ID Number:    6 digit number found on your certificate (Not a required field)

ACSM Certification number:     5 digit number found on your certificate (Not a required field)

*Salutation:

*Last Name:

*First Name: Middle:

*Preferred Mailing Address (for all ACSM mailings):

Home:

Work:

*City: *State:

*Postal Code: *Country:

*Please note this address will be used for all ACSM mailings.

Business Phone: *Home Phone:

Fax:

*E-mail Address:

*Certification Level(s):
CPT | GEL | ETT | H/FI | RCEP | ES | H/FD | PD

ACSM CECs applicable for this period:

Amount of CECs earned from other organizations:

Total CECs

 

Recertification / Renewal Fee (select one):
Note: Select the highest level recertification fee if recertifying multiple credentials.


If your re-certification cycle is from 1/1/2005 - 12/31/2008 please use this fee scale

CPT = $30
GEL = $40
 ETT = $40
ES = $60
H/FI = $60
RCEP = $60
PD =$80
H/FD = $80

If your re-certification cycle is from 1/1/2006 - 12/31/2008 please use this fee scale

CPT = $30
GEL = $30
 ETT = $30
ES = $45
H/FI = $45
RCEP = $45
PD =$65
H/FD = $65

Late Fee=$10

Multiple Recertification / Renewal Fee (if applicable)= $5

MULTIPLE CREDENTIALS
If you have gained professional ACSM credentials at more than one level you can choose which credential(s) you wish to keep current. The documentation for currency for one level can be duplicated for the other levels for the appropriate time period. For example, if you were certified as a Certified Personal Trainer in 2007 and you were certified as a Health/Fitness Instructor in 2006, you can update both certifications in 2008 (when your Health/Fitness Instructor will be due). By submitting enough credits for your Health/Fitness Instructor certification (60 credits) and by paying the higher level of recertification fee ($45) plus an additional $5 multiple certification fee, you can update both credentials to be on the same recertification.

Total:

All payments must be made in U.S. dollars. By submitting this form you are authorizing ACSM to charge your credit card.

*Charge to:

*Credit Card Number:

*Expiration Date (mm/yyyy):

I, by submitting this ACSM Recertification/Renewal Form, understand that continuing education credits and CPR certification are necessary components of, and requirements for, valid ACSM certification/registration. I confirm that I have met all of the requirements for this level of credential and will provide proof when necessary. I have completed the above application to the best of my knowledge and the information is accurate and true.

I have read, understand, and agree to the ACSM Recertification/Renewal policies.
Once we receive a complete ACSM Recertification/Renewal Form and payment, you will be sent new ACSM certificate(s). If you do not receive your new certificate(s) in 30 days, please contact the ACSM Certification Department at certification@acsm.org or 317-637-9200 extension 121.

 
©2005 ACSM. All rights reserved.


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