Application for the CLRP Designation

Application and Payment for the CLRP Designation and Membership

Name*
Address:
City*
State:
Zip:
Email*
Phone*
Your Age:
	Qualifications
	Do you have at least 4 years of college education? Yes No
	OR
	Do you have at least 4 years in activities or a profession related to the CLRP? Yes No
	Examples: Elder law or Estate planning Home care services Reverse mortgage Care management Financial advice or products for the elderly Veterans benefits Working in a care community or nursing home Care community placement services Any other activities or profession focused on helping aging seniors and their families
	Do you have a cumulative of college education and activities or a profession listed above that total at least 4 years combined? Yes No
	Convictions / Suspensions / Judgments
	Have you ever been convicted or imprisoned for a crime? Yes No
If yes, please explain
	Have you ever had a state or federal license revoked or suspended? Yes No
If yes, please explain
	Do you have any judgments against you? Yes No
If yes, please explain
	Certification / Submit Application
eSignature*
	With your eSignature (accepted in the form of /your full name/), you certify the statements and entries above are true and correct to the best of your knowledge.
What is 2 + 2?*
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