I. Personal Information

Candidate Details

*First Name
Middle Name
*Last Name
*Email
Profession
*Address
*City
State (For USA residents only)
Zip/Postal code
*Country
Work Number
Phone Number

For quesions or assistance contact: carrie.moraites@aabc-certification.org

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)

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

For quesions or assistance contact: carrie.moraites@aabc-certification.org

II. Academic Information

List Highest Academic Degree(s)

Degree #1
College/University
Year Received
Degree #2
College/University
Year Received
Degree #3
College/University
Year Received

List any licenses, registrations or certifications

License / Certificate / Registration
Where Held or Awarded
Year Received

License / Certificate / Registration #2
Where Held or Awarded
Year Received

License / Certificate / Registration #3
Where Held or Awarded
Year Received

For quesions or assistance contact: carrie.moraites@aabc-certification.org

III. Ethical, Legal or Professional Events

Have you been involved with any ethical, legal or professional proceedings such as an ethical hearing or malpractice lawsuit?

yes

no

Please explain the circumstance :

For quesions or assistance contact: carrie.moraites@aabc-certification.org

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.

For quesions or assistance contact: carrie.moraites@aabc-certification.org

Statement of Goals and Objectives

*List your goals and objectives as a candidate for the Bariatric Science Certificate Program:

For quesions or assistance contact: carrie.moraites@aabc-certification.org

Supporting Materials

If you are a licensed, registered, or certified health or education professional letters of reference may be sent after application submission.

  • Copies of licenses, registrations or certifications
  • A copy of a photo id such as work id, passport or driver license
  • Two letters of reference (at least one from a licensed health or education professional using an official letterhead.)

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:

Upload Documents

Mail Documents

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:
licenses/registrations or certificates: If you currently do not have a license/registration or certificate provide your highest academic degree transcript (official transcripts are not necessary).
    A copy of a photo id
      Two letters of reference - For licensed, registered, or certified health or education professionals reference letters may be submitted at a later date.

        For quesions or assistance contact: carrie.moraites@aabc-certification.org

        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

        By Check

        By Credit Card or PayPal Account

        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

        For quesions or assistance contact: carrie.moraites@aabc-certification.org