Apply to Become an AFA EIC Specialist Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Phone*Email* Enrollment Fee The enrollment fee for AFA EIC specialist is $245. This fee covers comprehensive training, including AFA’s Partners in Care training DVD, program materials, and administrative fees. Enrollment Fee*Fee $245.00Total $0.00 Credit Card* American ExpressDiscoverMasterCardVisa Card Number Expiration Date Month010203040506070809101112 Year20172018201920202021202220232024202520262027202820292030203120322033203420352036 Security Code Cardholder Name Please note: Payment will not be processed until your application is approved and a confirmation letter has been mailed to you. Qualification requirements An applicant must: Be a healthcare professional with at least three years of recent experience in dementia care (e.g., social workers, nurses, administrators, program directors/coordinators, geriatric care managers); Hold a minimum of a Bachelor’s degree and/or current license in their state. Educational HistoryVocational TrainingInstitutionLocationYears AttendedDegree Earned CollegeInstitutionLocationYears AttendedDegree Earned Post-collegeInstitutionLocationYears AttendedDegree Earned Upload Resume*Employment History Please attach your résumé to this application Drop files here or Accepted file types: doc, docx, pdf. Agreement By signing below, I certify that I have not withheld any information that might adversely affect my chances for selection as an Alzheimer’s Foundation of America (AFA) Excellence in Care (EIC) specialist and that all information I have given is correct. I understand that any omission or material misstatement on my application, resume or other document submitted in support of my application shall be grounds for rejection of my application. The Alzheimer’s Foundation of America does not discriminate based on an applicant’s gender, race, ethnicity, national origin, religion, age, marital status, veteran status, disability, sexual orientation, or any other category protected by local, state, or federal law. NameSignature*Date
Apply to Become an AFA EIC Specialist Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Phone*Email* Enrollment Fee The enrollment fee for AFA EIC specialist is $245. This fee covers comprehensive training, including AFA’s Partners in Care training DVD, program materials, and administrative fees. Enrollment Fee*Fee $245.00Total $0.00 Credit Card* American ExpressDiscoverMasterCardVisa Card Number Expiration Date Month010203040506070809101112 Year20172018201920202021202220232024202520262027202820292030203120322033203420352036 Security Code Cardholder Name Please note: Payment will not be processed until your application is approved and a confirmation letter has been mailed to you. Qualification requirements An applicant must: Be a healthcare professional with at least three years of recent experience in dementia care (e.g., social workers, nurses, administrators, program directors/coordinators, geriatric care managers); Hold a minimum of a Bachelor’s degree and/or current license in their state. Educational HistoryVocational TrainingInstitutionLocationYears AttendedDegree Earned CollegeInstitutionLocationYears AttendedDegree Earned Post-collegeInstitutionLocationYears AttendedDegree Earned Upload Resume*Employment History Please attach your résumé to this application Drop files here or Accepted file types: doc, docx, pdf. Agreement By signing below, I certify that I have not withheld any information that might adversely affect my chances for selection as an Alzheimer’s Foundation of America (AFA) Excellence in Care (EIC) specialist and that all information I have given is correct. I understand that any omission or material misstatement on my application, resume or other document submitted in support of my application shall be grounds for rejection of my application. The Alzheimer’s Foundation of America does not discriminate based on an applicant’s gender, race, ethnicity, national origin, religion, age, marital status, veteran status, disability, sexual orientation, or any other category protected by local, state, or federal law. NameSignature*Date
