If you would like to download the form and send it to the Pee Dee AHEC, please click on the link below. If you would like to continue to use the online version of the form, simply fill out the information below.

CE Duplicate Certificate Request Application

Fill the form out completely. Uncompleted forms will be discarded. To move the form, click and hold on the word move in the top right hand corner and drag it where desired.

There is a $5 charge for each duplicate certificate to replace lost ones or those not picked up at the completion of the program.

Requests for certificate(s) dated back more than 5 years will not be honored.

Fields marked with a * are required.

* Your First Name:

Your Middle Name:

* Your Last Name:

Your Maiden Name:

Suffix:

* Your Email:

* Your Mailing Address:

* City:

* State:

* Zip Code:

* County:

Phone Number 1:

Phone Number 2:

* Name of Program:

* Date of Program:

* Place of employment at the time the class was taken: