Clinical Experience Verification Form

Applicant Information *

Credential Applicant

Please enter the name of the person seeking a professional credential with Breining Institute, who has requested that you provide verification of clinical hours.

Applicant Name: *

City / State: *

Please enter the name of the city and State where the credential applicant currently works or resides. If you do not know the city and State where the applicant currently works or resides, please include the last known city and State.

Employer Information *

Employer Information

Here we are requesting information about the applicant's employer. We are also requesting contact information for you, so that we will be able to contact you if we need follow-up information about the applicant's clinical experience.

Name of employer: *

Address of employer: *

Please include street address, city, State or Province, and ZIP code or Country code.

Employer website: *

If employer does not have a website, you may include its social media page (such as Facebook, LinkedIn, or similar page), or you may include "Not applicable" as an answer.

Your Name: *

Your Title or Position with company: *

Email Address: *

Please enter your current Email address, so that we will be able to contact you if we have further questions about this applicant.

Confirm Email Address: *

Please re-enter your email address here

Primary Phone Number *

Your professional license(s) or certification(s)

If you currently hold professional human resources or healthcare licenses or certifications, please list them here.

Experience Verification *

Applicant's title or position: *

Please let us know the applicant's current or most recent title or position with the employer. If applicant had several positions, please include any that might be relevant to the credential being sought by applicant.

Brief description of applicant's responsibilities: *

Please use this space to briefly describe applicant's responsibilities while with your company. If applicant held several positions, you may include brief descriptions of those responsibilities which are relevant to the credential being sough by applicant.

Dates of employment: *

Please provide a starting date and ending date (or indicate that the applicant is still employed) with this company. If there were breaks in employment, please indicate.

Hours of employment: *

Please estimate the total number of hours the applicant was working for this company in the capacity or capacities related to the title and responsibilities provided above. "Full time" work equals approximately 2,000 hours per year.

Attestation:

By submitting this form, you attest that you are or were in a position with this employer to provide accurate information about this applicant, and the information you have provided is true and authentic, to the best of your knowledge. And you understand if at any time it is determined the information provided is materially misrepresented, any credentials awarded by Breining Institute to the applicant may be revoked.

Are you ready to submit this form?

We appreciate you taking the time to provide this Experience Verification for the person seeking to be awarded a professional credential from Breining Institute.

If you are satisfied with your responses, please select the “Submit” button below, and this Experience Verification Form will be submitted to Breining Institute.

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