Certification Renewal - International Christian Chaplains Association

Full Name

Email Address

Street Address

City

State

Zip

Primary Phone

Work Phone

Date of Birth

Today's Date

Certification Issue Date

Certification Expiration Date

ICCA Certification Number

Name of Instructor

Are you currently employed by a church or ecclesiastical body?

YES

Have you been a defendant in a malpractice suit and either entered into a settlement agreement or paid court awarded damages?

YES

Have you been arrested or charged for the commission of any felony or any crime involving moral turpitude?

YES

Have you been convicted of any felony or of a crime involving moral turpitude?

YES

Have you been the subject of disciplinary action or had your membership revoked by a professional organization governing the practice of counseling, either secular or religious?

YES

RENEWAL PAYMENT FEE

$50

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ICCA Certificate Renewal