Form 08-4215b - Academic Program Completion Certification

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State of Alaska
Department of Community and Economic Development
Division of Occupational Licensing
Board of Certified Direct-Entry Midwives
P.O. Box 110806
Juneau, Alaska 99811-0806
(907) 465-2580
E-mail: license@dced.state.ak.us
ACADEMIC PROGRAM COMPLETION CERTIFICATION
(Required for examination application)
The following section needs to be completed by the applicant's preceptor. (NOTE: If an applicant has more than
one preceptor, please make photocopies and submit with the application.)
I,
, am a
(Name of Preceptor - Print)
licensed
and have been practicing
for
year(s) and certify that
has completed the
academic portion of her/his apprenticeship under my direction. The academic program meets the course of study
requirements of 12 AAC 14.200 and has been in duration for at least one year.
NAME OF ACADEMIC PROGRAM
Via Vita School of Midwifery - Fairbanks, AK
(907) 456-3719
Seattle School of Midwifery - Seattle, WA
(206) 322-8834
National College of Midwifery - Taos, NM
(505) 758-1216
Midwifery Education Foundation - Fairbanks, AK
(907) 456-3719
Ancient Art Midwifery Institute - Clairmore, OK
(918) 342-2926
Other:
Signature of Preceptor
License/Certification Number
State
Date
SUBSCRIBED AND SWORN TO before me this
day of
19
.
Notary Public
SEAL
My Commission Expires:
08-4215b (Rev. 11/99)

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