I. Personal Information Employer Details (Optional) Employer Name
Employer Address
Employer City
Employer State
Employer Zip code
Employer Phone
Employer Email
* How were you referred to AABC? (you can select more than one choice)
Select atleast one choice
Hospital or Health Facility
College or University
Email
LinkedIn
Facebook
Web Search
My employer
Academy of Nutrition and Dietetics
National Board for Certified Counselors
American Society of Metabolic and Bariatric Surgery
Other
Honors, Awards, Publications (Optional) List any honors and/or awards received including places and dates of honors and publications including reference citations.
Memberships and Affiliations (Optional) List current memberships in professional associations, committees, societies, boards, etc. including types of membership (i.e., member or associates) and dates of memberships.
Supporting Materials If you are a licensed, registered, or certified health or education professional letters of reference may be sent after application submission.
You can choose to upload Your Supporting Materials here, or mail hard copies to: The American Association of Bariatric Counselors, 110 Chestnut Ridge Road, Suite 137 Montvale, NJ 07645.
* Please choose one of the options:
JPG or PDF file types are allowed :
Please mail application and supporting documents in a 9" x 12" (or larger) mailing envelope so that pages will be flat for digital scanning.
transcripts -For licensed, registered, or certified health or education professionals transcripts may be submitted post application submission:
VII. Your Signature I affirm the veracity of all statements made by me are true in this application for Admission to Bariatric Science Certificate Program
* Signature (Type your full name):
Signature
Signature Date
* Application Fee payment option (choose one):
A $ 75.00 application fee
Please Send A $ 75.00 application fee by check made payable to American Association of Bariatric Counselors to:
American Association of Bariatric Counselors 110 Chestnut Ridge Road, Suite 137 Montvale, NJ 07645
If you have any questions or need any assistance contact Carrie.Moraites@aabc-certification.org