MECH

Recertification Registration Form

As stated in your Recertification Announcement Letter, you have the opportunity to take advantage of staggered registration. The details are as follows:

  1. The first 200 certificate holders who respond to MECH, based on this announcement, will be allowed 6 years (rather than 5 years), to recertify. The first 200 who respond will recertify during the year 2012.
  2. The second, or next 200 certificate holders who respond, will have the standard 5 years and will recertify in 2011.
  3. The third group, or last 200 certificate holders who respond, will have 4 years to recertify, during 2010.
  4. The remainder of MECH Certified mechanics who respond will have 3 years to recertify and will recertify during the year 2009.


  (Required Field=*) All required fields (blanks) must be filled in. This information is necessary to verify the authenticity of your application with your data on file. None of this information is shared or sold to advertisers!


First Name*    Middle Initial * *Last Name

Last 4 digits of your Social Security Number*

E-mail Address*

Your Current Certification Level
(one must be checked *)
 Certified     OR    Senior Certified

 

Job Title*

Healthcare Institution Name*

Healthcare Institution Address*

Healthcare Institution City*

Healthcare Institution State (two letters)*       Healthcare Institution Zip Code*

Phone*    Extension    Fax*
000-000-0000                   0000                      000-000-0000

 

Home/Residence Address*

Home/Residence City*

State of Home/Residence (two letters)*       Zip Code of Home/Residence*

Phone (land line or cell phone)*   
000-000-0000

Click here when the form is complete