ALS EXTENSION AFFIDAVIT/APPLICATION

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STATE OF ___________ )

) ss.

COUNTY OF _________ )

I, _____________________________________________, hereby affirm that 

• I have, since my certification, earned the 15 hours necessary to extend my ALS certification; 
• that I have not violated the NALS Code of Ethics and Professional Responsibility, been convicted of a felony, nor received a determination of the unauthorized practice of law; 
• that I understand falsification of information provided to NALS may result in my ALS certification being revoked.

Dated Signature _____________________________________Subscribed and affirmed before me on ________________, 20____.

________________________________________________________________
Notary Public

________________________________________________________________
Printed Name of Notary

________________________________________________________________
My commission expires
Applicant's Name/Address/Certification Information

________________________________________________________________ 
Applicant's Name (please print)

NALS Member No.: _____________________

Social Security No.: _____________________

________________________________________________________________
Former Name(s) (maiden/married, etc., since
original certification)

________________________________________________________________
Address

________________________________________________________________
City, State, Zip

Day Phone: ______________________________________________________ 

Evening Phone: ___________________________________________________ 

Certification Date (month/year): ______________________________________

Fax: ____________________________________________________________

E-Mail Address: ___________________________________________________

Fee $30 payable by check or use your charge card: 

___ Visa ___ MC DiscoverCredit Card No.: _____________________________

Expiration Date:___________________________________________________

Signature: ________________________________________________________

* Please print form and mail *
RETURN TO:
NALS -- ALS Recertification
8159 East 41st Street
Tulsa, OK 74145
(918) 582-5188 ext. 12
Fax: (918) 582-5907
E-Mail: info@nals.org

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SECTION A -   SEMINARS/WORKSHOPS ATTENDED

NOTE: Complete this section ONLY if you do not have a certificate of attendance for the seminar or workshop or other documentation confirming participation in the program, OR if you are requesting points for watching a video tape or listening to an audio tape.

Number Date of Program Session Topic
(include description of topic and name of Hours Event Sponsor speaker)Total hours : X 1=

__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

 

__________________________________________________________________________________
(Signature of sponsor representative or coordinator, if available;a signature is not required to receive extension credit)

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SECTION B -  SEMINARS/WORKSHOPS TAUGHT

NOTE: Complete this section to verify teaching a seminar or workshop ONLY when other documentation is not available.

Number Date of Program Session Topic
(include description of topic and name of Hours Event Sponsor speaker)Total hours : X 1=

__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________

 

__________________________________________________________________________________
(Signature of sponsor representative or coordinator, if available;a signature is not required to receive extension credit)

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SECTION C -  PETITION FOR HOURS

NOTE: Complete this section to request hours for writing publications OR for 
participating in activities not included in other modules.

Attach documentation to verify participation.

Requested hours: ____________________________________________________

Date of activity: ______________________________________________________

Description of activity:  ________________________________________________

Reason for petitioning for the requested hours: _____________________________

Name of program sponsor: _____________________________________________

 

__________________________________________________________________________________
Signature of sponsor representative or coordinator, if available:
a signature is not required to receive extension credit.