JCAHPO Application for Examination
Please type or print clearly . Please refer to the Criteria for Certification and Recertification handbook for instructions on completing this application .
1 . Examination Type
Please check the examination for which you are applying : o COA ($ 300 ) o COA Practice ($ 150 ) o COT o COMT o OSA o ROUB o CCOA o CDOS Please check one of the following : o Rush fee enclosed . Please refer to the payment section below . o This is my first time applying for this exam . o I have taken this exam previously - Last test date :____/____( month / year ) o I am taking this exam to recertify my credential in lieu of continuing education credits .
2 . JCAHPO Identification Number ( if applicable )_
ID #_____________________________ 3 . Applicant Your name will appear on your certification as written here . IMPORTANT : The name on your two forms of identification that will be presented at the testing center when you take the exam must match exactly the name provided below .
Name : o Mr . o Mrs . o Ms .
Date of Birth : ( mm / dd / yy ) ______/______/______
First Middle Last Suffix Former name ( if applicable )
Home Address Apt . #
City State Zip Code Country
Home Telephone Business Telephone
E-mail
FAX NOTE : Notify JCAHPO of any name or address changes . Official examination correspondence will be mailed to your home address .
Applicant ’ s highest educational credential completed . ( Check one box and indicate subject / discipline as appropriate .) o High school diploma o Two year college ( Associate ) degree o Bachelor ’ s degree o Master ’ s degree o Other : _______________ Subject / Discipline : _____________________________________________________________________________________________________________________ Applicant ’ s occupational background ( Check all that apply .) o Certified Orthoptist o Contact Lens Technician o Ophthalmic Photographer o Optician o Registered Nurse o Other : _______________ 4 . Eligibility
NOTE : Your application will not be processed if the appropriate section below is not completed . See the Criteria handbook for further explanation of the eligibility criteria . Supporting documentation of your education ( such as a transcript or a copy of a certificate of completion ) must be attached .
COA Applicants - Check only one box . o Graduate of formal clinical training program ( A1 ) o Graduate of formal training program and work experience ( A2 ) o Completion of independent study course and work experience ( A3 )
COT Applicants - Check only one box . o Graduate of formal training program ( T1 ) o Currently certified as a COA and work experience ( T2 ) o Currently certified as an orthoptist and work experience ( T3 ) o Currently certified as a COA and non-certified work experience ( T4 )
COMT Applicants - Check only one box . o Graduate of formal training program and two or more years of college education ( TG1 ) o Graduate of formal training program , less than two years of college education , and work experience ( TG2 ) o Currently certified as a COT and work experience ( TG3 ) o Currently certified as an orthoptist and work experience ( TG4 ) o Current COT , work experience as a COT , and non-certified work experience ( TG5 )
OSA Applicants - Check only one box . o Graduate of formal clinical training program ( SA1 ) o On-the-job training ( SA2 ) o Approved Surgical Assisting Course ( s ) and Surgical Log ( SA3 )
I comply with the criteria that corresponds to the selection made above and have attached copies of the required documentation .
ROUB Applicants o Graduate of formal training program ( R1 ) o Currently certified by JCAHPO as a COA , COT , COMT , or CDOS , and work experience ( R2 ) o Earned CE credits in classroom setting , handson course , and work experience ( R3 )
CDOS Applicants o Graduate of formal training program ( B1 ) o Currently certified as a COA , COT , COMT , ROUB , RDCS , RT ( S ) or CRA , and work experience ( B2 ) o Earned CE credits in classroom setting , handson course , and work experience ( B3 )
CCOA Applicants o Completion of independent study course and current employment with supplier of ophthalmic products and / or services .
X ____________________________________________________________________________________________________________________________________________ Signature
Date
5 . Payment Indicate method of payment ( please refer to the fee schedule in the criteria handbook for amount ):
Group Code if Applicable :_________________
o Check / Money Order ( drawn on a U . S . bank , in U . S . dollars , payable to JCAHPO ) o VISA o MasterCard o Discover o American Express o $ 50.00 Rush Processing Fee
If payment is by credit card , please provide the following information :
Card Number Security Code Expiration Date ( month / year )
Payer ’ s Name ( please print ) Authorized Signature
Payer ’ s Billing Address Payer ’ s Zip Code
39