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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 Certified Clinical Exercise Specialist (CES)
ACSM Certified Health Fitness Specialist (HFS)
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 | HFS | RCEP | CES | 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 you received your certification or last recertified in 2004 ONLY please use the following scale:

CPT = $30
GEL = $40
 ETT = $40
CES = $60
HFS = $60
RCEP = $60
PD =$80
H/FD = $80

If you received your certification or last recertified in 2005 or after please use the following scale:

CPT = $30
GEL = $30
 ETT = $30
CES = $45
HFS = $45
RCEP = $45
PD =$65
H/FD = $65

Late Fee=$25 (A late fee of $25.00 will automatically be charged to your credit card when submitting this form for recertifying after your certification has expired)

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 Certified Health Fitness Specialist in 2006, you can now update both certifications in the same year that your Certified Health Fitness Specialist will be due). By submitting enough credits for your Certified Health Fitness Specialist 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:

If the late fee is not checked above and your certification has expired, the late fee will be added to this total automatically and charged to the credit card below. 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

 
©2005 ACSM. All rights reserved.


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