Request Form For Extension Disability Or Retirement Extension

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Request Form for Extension, Disability, or Retirement
I, _________________________________________, request one of the following:
Print Name
EXTENSION
I was unable to complete the required 20 Continuing Education hours for this cycle due to
circumstances that meet specified criteria. If approved, I understand that this will allow deficient
hours from one CE cycle to be obtained in the next two-year CE cycle period.
CE Cycle Dates ________________________
Number of CE Hours Acquired* ___________
*Please include a CE Summary Form if you have any CE hours
DISABILITY RELEASE
I was unable to complete the required 20 Continuing Education hours for this CE cycle due to
unemployment because of a disability, which limited participation in CE activities. Medical
documentation of the impairment must be provided. This release applies for the term of your
disability and only to situations with the actual individual, not family members.
RETIREMENT of CTR REQUIREMENTS
I do not continue to use your CTR credential, then request a permanent release of the CE
requirements of submitting 20 CE’s every two years AND paying the annual CTR Maintenance
Fee.
Explain the reason for your request:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________.
Number of Pages Submitted_________
Signature __________________________________________ Date_________________
 Submit to NCRA by one of these methods:
Mail: 1330 Braddock Place #520, Alexandria, VA 22314
EM: , or FAX# (703) 299-6620
For NCRA Staff Use:
______Extension
________Disability
__________Retirement
Date Submitted for Approval______________ Status ___________
Date Notified Requestor _________________________________
Membership Type ___________________________________________

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