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* 1. Full Name

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* 3. Job Status

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* 4. Employment Information

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* 5. Eligibility Confirmation

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* 6. Please briefly describe your current professional status and why you are no longer able to meet ACA recertification requirements.

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* 7. Acknowledgments (all items must be checked to proceed)

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* 8. Signature (typed name)

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* 9. Date

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