Information on Courses / Seminars for PDCs

List each course/seminar/PDC item you will use to meet your PDC requirement in the box below. You can find more details about PDCs on page 8 of the Licensing Program Guidelines.

You can list multiple courses/seminars/PDC items in this box.

For each, please enter the following information in the box:

The course/seminar/PDC item name
Date completed
Provider/Organization
PDC value (1 PDC per contact hour)

Then add up the number of all PDCs and enter this in the lowest box.

PDC Total*

PDC Information*

CPR & Liability Insurance

If you are not actively seeing clients, you are exempt. Please check the appropriate box below.

-OR- If you are actively seeing clients, please complete both CPR and Liability Insurance questions.

I am not actively seeing clients and am exempt from the CPR and liability insurance requirement

I hold current CPR certification

I live in a state/country that does not require CPR certification

I have current liability insurance coverage

Liability insurance is not available in my area

Medical Facility Information

If you have Staff Members who are CHEK Professionals and want to renew their licenses, please be sure to complete the "Licensed Staff" field below so that we can send them to the proper licensing form.

Facility Address*

Licensed Staff - Full Name + Email*

Medical Field & Degree*

Important - Terms of Renewal

I accept and agree to adhere to the CHEK Institute Code of Conduct. I hereby certify that the information contained on this License Application Form and PDC Checklist is true, complete and correct.

Digitally signing this form with your full name signifies that everything you have stated on this form is true and accurate. In addition, you have documentation to support your claim and are able to furnish a copy of that documentation to the C.H.E.K Institute if requested.

The CHEK Institute reserves the right to audit License applications at random to ensure compliance.

Signature*