CAAHEP
Request of Accreditation Services Application
* Denotes Required Field(s)
This form will be submitted to:

,
Institution Information
Profession: *
This is a request for: *
Institution Name: *
Institution City: *
Institution State: *
Institution Website: *
Institution Type: *
Institution Control: *
Name of INSTITUTIONAL accrediting agency: *
Type of award? (indicate all that apply): *

CAAHEP defines a distance education program as a program that allows completion of the entire curriculum without the need to attend any instruction on a campus location (clinical rotations excluded). Note: this delivery is not hybrid or partial e-learning delivery.
Is the program a distance education program?: *
Indicate all that apply
Describe the distance learning: *
Program Length (months): *
List month(s) classes begin each year: *
Students First Accepted Month: *
Students First Accepted Year: *
Where did you hear about CAAHEP accreditation?:
Program Director
First Name: * Last Name: *
Credentials: * Title: *
Institution Name: * Address: *
Address 2: Address 3:
City: * State: *
Zip Code: * Phone: *
Fax: Email: *
Dean
First Name: * Last Name: *
Credentials: * Title: *
Institution Name: * Address: *
Address 2: Address 3:
City: * State: *
Zip Code: * Phone: *
Fax: Email: *
Medical Director/Advisor
First Name: * Last Name: *
Credentials: * Title: *
Institution Name: * Address: *
Address 2: Address 3:
City: * State: *
Zip Code: * Phone: *
Fax: Email: *
CEO
First Name: * Last Name: *
Credentials: * Title: *
Institution Name: * Address: *
Address 2: Address 3:
City: * State: *
Zip Code: * Phone: *
Fax: Email: *
Individual Completing this form
Name: *
Working Title: *
Email: *
Phone: *
CEO Authorization
CEO Signature: *
By entering my name above, I attest that I am the CEO and that I have authorized initiation of the accreditation process. In addition, by entering my name above, I consent to the use of this electronic method of contract acceptance under the U.S. Electronic Signatures in Global and National Commerce Act (E-Sign); and I have read and agree to the terms and conditions in CAAHEP Copyrights and Permissions.
Date: 2/3/2012
CAAHEP