NOTE: Be sure that your certification is still valid before updating your info.

Please Fill Out All the Information Requested in the Following Form


Select the current CBSPD Certifications that you have

Technician (CSPDT)

Surgical Instrument Processor (CSIP)

Flexible Endoscope Reprocessor (CFER)

Ambulatory Surgery Technician (CASSPT)

Supervisor (CSPDS)

Manager (CSPDM)

Certification Month/Year:

Last 4 digits of your SS#:

NICHSPDP/CBSPD ID#:

"Old" Name & HOME Address

Name:

Address:

City/State/Zip Code:

Foreign Country:

Home Phone:

Work Phone:

Work Extension:

Name:

Address:

City/State/Zip Code:

Foreign Country:

Home Phone:

Work Phone:

Work Extension:

E-mail:

What & When was the last item of mail you received from the CBSPD?:

Comments:

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