Request for Continuing Education Replacement Records

Please complete ALL fields.

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* 1. First Name

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* 2. Last Name

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* 3. Credentials

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* 4. Please submit a state or federal ID with photo.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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* 5. State of Licensure (for US only)

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* 6. License Number (for US only)

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* 7. Please provide a URL link for license verification.

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* 8. This Continuing Education Record Request is for: (Please include date(s) of program)

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* 9. Please release my record(s) to:

Myself

Other - A company or person of my choosing. Please include company and contact information.

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* 10. Email

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* 11. I give permission to release my records to the person or company listed above.

Agree

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* 12. I acknowledge that there is a $75 fee associated with my request if I am not an active member of the National Lymphedema Network (NLN) at the time of my request, which has been completed via the following link: https://lymphnet.kindful.com/?campaign=1105947 . I understand that this fee is waived if I am an active NLN member at the time of my request.

Agree

I am an NLN member.

I will join now! https://nlnmembership.com/

Thank you for completing this request. Please note that you should receive the requested materials within 7-10 business days, unless additional information is required.