Apply to Become an AFA EIC Specialist 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 HistoryName* First Last Address* Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code 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. **If you are currently certified as an AFA Dementia Care Partner and want to be an EIC specialist, please call our offices at 866-232-8484Upload Resume*Employment History Please attach your résumé to this application Drop files here or Accepted file types: doc, docx, pdf. Enrollment Fee*Fee $245.00Total $0.00 Credit Card* American ExpressDiscoverMasterCardVisa Card Number Expiration Date Month010203040506070809101112 Year20182019202020212022202320242025202620272028202920302031203220332034203520362037 Security Code Cardholder Name 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. How did you hear about AFA’s Excellence in Care (EIC) Dementia Care Program of Distinction?AFA websiteAFA mailing (postcard or e-mail)AFA publication (e-newsletter or AFA Care Quarterly)AFA social servicesEmployer/colleagueFriend/family memberNewspaper/magazine/TV or radioNameSignature*Date
Apply to Become an AFA EIC Specialist 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 HistoryName* First Last Address* Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code 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. **If you are currently certified as an AFA Dementia Care Partner and want to be an EIC specialist, please call our offices at 866-232-8484Upload Resume*Employment History Please attach your résumé to this application Drop files here or Accepted file types: doc, docx, pdf. Enrollment Fee*Fee $245.00Total $0.00 Credit Card* American ExpressDiscoverMasterCardVisa Card Number Expiration Date Month010203040506070809101112 Year20182019202020212022202320242025202620272028202920302031203220332034203520362037 Security Code Cardholder Name 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. How did you hear about AFA’s Excellence in Care (EIC) Dementia Care Program of Distinction?AFA websiteAFA mailing (postcard or e-mail)AFA publication (e-newsletter or AFA Care Quarterly)AFA social servicesEmployer/colleagueFriend/family memberNewspaper/magazine/TV or radioNameSignature*Date
