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1. Full Name (Required.)

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3. Job Status (Required.)

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4. Employment Information (Required.)

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5. Eligibility Confirmation (Required.)

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

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

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8. Signature (typed name) (Required.)

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9. Date (Required.)

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