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Eligibility to Earn ASHA CEUs Form

As of July 2011, individuals who are not ASHA members or ASHA certificate holders must demonstrate that he/she is eligible to earn ASHA CEUs by providing documentation for one or more to the following areas:

  • Licensed by a state or provincial regulatory agency to practice speech-language pathology (SLP) or audiology
  • Credentialed by a state regulatory agency to practice SLP or audiology
  • Credentialed by a national regulatory agency to practice SLP or audiology
  • Currently enrolled in a masters or doctoral program in SLP or audiology
  • Engaged in a Clinical Fellowship under the supervision of an individual with their ASHA Certificate of Clinical Competence (CCC)

You may demonstrate your eligibility by completing the applicable information below.

* indicates required field.

Contact Information

First Name:*

Last Name:*

Mailing Address:*

City:*

State:*

Zip Code:*

Phone Number:

E-mail:

ASHA Account Number:


I am eligible to earn ASHA CEUs because I am:

     

Proof of Eligibility

Please fill in the eligibility information for the categories you selected above.

License Information

State or Province:

Last Name on License:

First Name on License:

Licensed to Practice (e.g., speech-language pathology or audiology):

License Number:

State or Province Credential Information

State or Province:

Last Name on Credential:

First Name on Credential:

Credentialed to Practice (e.g., speech-language pathology or audiology):

Credential Number:

National Credential Information

Name of Credentialing Organization:

Last Name on Credential:

First Name on Credential:

Credential Number:

Institution Name:

Degree Type:

Degree Area:

Graduation Date (MM/DD/YYYY):

Speech Pathology ASHA Clinical Fellowship Information

SLP Clinical Fellow Mentor's First Name:

SLP Clinical Fellow Mentor's Middle Initial:

SLP Clinical Fellow Mentor's Last Name:

Mentor's ASHA Account Number:

Clinical Fellowship Beginning Date (MM/DD/YYYY):

Clinical Fellowship Ending Date (MM/DD/YYYY):

Masters or Doctoral Program Information

Institution Name:

Degree Type:

Degree Area:

Expected Graduation Date (MM/DD/YYYY):


Additional Information

Please provide additional information regarding your eligibility to earn ASHA CEUs.


Attestation

I attest that the information provided is accurate and that I am eligible to earn ASHA CEUs.

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