National Institute for Standards
in Pharmacist Credentialing

CDM MAINTENANCE APPLICATION

The CDM Maintenance process assures the profession, as well as the public, that NISPC credentialed pharmacists are evaluated periodically to verify that their knowledge and skills are kept current. NISPC requires all credentialed pharmacists to provide proof of education within their specialty area each year. Carefully read the CDM Maintenance Requirements and Guidelines before completing this application. Follow the steps below to complete the CDM maintenance process.

STEPS TO MAINTAIN YOUR CDM

·  1. Review the CDM Maintenance Requirements and Guidelines as well as the Application

·  2. Complete the continuing education record.

·  3. Complete the application.

·  4. Attest that you have a current, valid pharmacist license.

·  5. Enclose the application fee. Make checks payable to "NISPC" or pay by credit card online.

·  6. Submit the information on-line or mail the completed application, continuing education record, copy of your current valid Pharmacist license and payment to:

NISPC • 1600 Feehanville Drive • Mount Prospect, IL 60056

Continuing Education Record

List completed continuing education programs. You may photocopy this blank form if more space is needed.
DO NOT ATTACH COPIES OF YOUR CONTINUING EDUCATION CERTIFICATES.

You must fill out a separate form for each disease state.

Program TITLE
provider
ACPE/ CME
acpe approved number
date hours earned
number of hours
TOTAL NUMBER OF HOURS

I affirm, under penalty of perjury, that the information I have submitted on this record is true and correct to the best of my knowledge and belief. I declare that I am a NISPC credentialed pharmacist.

I AGREE Name:
Date Disease State:

 

CDM MAINTENANCE APPLICATION
Identify the disease state(s) in which you are seeking maintenance:

Anticoagulation Certificate number:
Year Received:
Asthma Certificate number:
Year Received:
Diabetes Certificate number:
Year Received:
Dyslipidemia Certificate number:
Year Received:

Personal Information:

Name:
    Last   M.I.   First
Office Address:
    Street   City   State   Zip
Residence:
    Street   City   State   Zip
 Send mail to: Office Address | Residence Address
Home Phone:
Office Phone:
 
E-mail:
Fax Number:
 
Employer:
Title:
 

Licensure

I affirm, under penalty of perjury, that my pharmacist license is current and valid in the state where a substantial portion of my practice takes place.

Application Acknowledgment

  • I have read and comprehend all the information contained in the CDM Maintenance Requirements and Guidelines.
  • I have enclosed the application fee.
  • I will send a copy of my current, valid, pharmacy license.
  • I understand that NISPC will continue to include my name and address under the list of credentialed pharmacists on both the NISPC and NABP websites.
Check here if you would like for your name NOT to be included in the list of NISPC credentialed pharmacists on the above-mentioned websites.
  • I further understand and agree that NISPC may release aggregate data to individuals and organizations for the purpose of promoting the NISPC credential, on the condition that my identity will not be disclosed.
  • I understand that NISPC reserves the right to audit my CE certificates at anytime.
  • I affirm, under penalty of perjury, that the information I have submitted on this application is true and correct to the best of my knowledge and belief.
  I agree
 I do not agree		 Your Name:

CLICKING THE 'CONTINUE' BUTTON BELOW WILL TRANSFER YOU TO A SECURE CREDIT CARD
PAYMENT FORM FOR APPLICATION FEES. APPLICATIONS SUBMITTED WITHOUT
CREDIT CARD PAYMENT WILL NOT BE PROCESSED.

National Institute for Standards
in Pharmacist Credentialing
www.nispcnet.org