Wake AHEC Duplicate CE Credit Certificate Request

Credit card payment is required, secured, and confidential.  We accept American Express, VISA, MasterCard, and Discover.  Please have your credit card ready.  A Wake AHEC customer service representative will process your request.  If you have any questions or concerns, please call 1-866-341-1814 (toll free) or (919) 350-8547 during business hours:  9am - 4pm (US, Eastern Time), Monday - Friday. 

To help us find your record, please enter your information on this form.
 
*Required Fields  Program Information
*Date of Program:
*Name of Program:
 * Required Fields   Your Information
 *Name:
First Name Initial Last name
Salutation: Mr. Mrs. Ms. Dr.
*Degrees/Certifications:
   If not applicable, enter NA.
*Home address:
 
*City:
*State:     *Zip:
 *Phone (Home): ()   -
*Occupation:
NABP e-Profile ID: Pharmacists and Pharm Techs only
Birth - MMDD: Pharmacists and Pharm Techs only
Employer:
County of Work:
Work address:
 
Work City:  
Work State:       Work Zip:
 Phone (Work): ()   - Ext.
 Fax (Work): ()   -
 Would you like to receive program announcements?
  Check to receive announcements
*Email (Home or Office):
Valid Email address required
*How did you hear  about Wake AHEC?
 
 How do you prefer to receive your certificate?
(check one only)

Fax (7-10 business days)
eMail to my home (up to 5 business days)
eMail to my work (up to 5 business days)



* Please enter the letters and/or numbers you see above:

 

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 Fees
$15.00