90 Day Late Fee Renewal Form 90-Day Renewal Form CompanyThis field is for validation purposes and should be left unchanged.Today's Date* Gender* Male Female I understand that as a NRRTS Registrant I will receive periodic, non-marketing digital notifications directly from NRRTS.* Yes What Year Were You Born?*YEAR onlyName* First Last First Name You Go By*Business Name*Preferred Mailing Address* Business Home Business Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzechiaDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussian FederationRwandaSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTürkiyeTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Business Phone*Preferred Email* Alternate Email* Company Website*Home Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzechiaDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussian FederationRwandaSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTürkiyeTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Mobile Phone*Do you have the RESNA ATP?* Yes No RESNA ATP Expiration Date Do you have the RESNA SMS?* Yes No Did you complete your education with NRRTS?*If you completed your education with NRRTS, you do not need to upload education. We have your education on file. Each year, you must complete 10 hours of CRT education, which translates into 1 Continuing Education Unit (CEU). Continuing education must be in the field of CRT. If education was applied to your renewal last year, the education cannot be used again. Yes No Upload Non-NRRTS CEUs Drop files here or Select files Max. file size: 50 MB. Upload Business Card Drop files here or Select files Max. file size: 50 MB. Affirmation of Good Moral CharacterWe require that you answer the following questions that address issues that may be harmful to the public or inappropriate to the profession. A “yes” answer will not necessarily result in a denial of registration or renewal. However, failure to fully disclose any relevant information will be considered grounds for denial of Registration or renewal. No applicant or registrant will be denied registration or renewal solely on the grounds of conviction of a criminal offense. The nature of the offense, the date of the offense, the surrounding circumstances and the relevance of the offense will be considered. This includes any expunged records in any legal jurisdiction.1. Have you ever been found guilty of, pled guilty or no contest to, entered into a plea agreement instead of prosecution, or found guilty without conviction (adjudication withheld) on a felony charge in any legal jurisdiction? Failure to disclose any relevant information will be considered grounds for denial* Yes No 2. Have you ever been found guilty of, pled guilty or no contest to, entered into a plea agreement instead of prosecution, or found guilty without conviction (adjudication withheld) on a misdemeanor involving theft, fraud, bribery, corruption, perjury, embezzlement, solicitation, dishonesty, physical harm or threat of physical harm to the person or property of another or substance abuse in any legal jurisdiction?* Yes No 3. Have you ever been subject to an adverse civil or administrative judgment for theft, fraud, corruption, embezzlement, solicitation, dishonesty, substance abuse, or any offense that calls into question the integrity or judgment of your actions?* Yes No 4. Are you currently or ever been subject to sanction, reprimand, suspension, or restriction by any governmental agency, professional body, association, licensing authority, board or certifying association of which you were or are a member or subject to its jurisdiction?* Yes No 5. Have you ever been discharged from employment for theft, fraud, corruption, embezzlement, solicitation, dishonesty, substance abuse, or any offense that calls into question the integrity or judgment of your actions?* Yes No If you answers "Yes" to any section, please provide detailsRegistrant Signature*By signing below you affirm that your answers to the above questions are true and that you agree to abide by the NRRTS Code of Ethics; Standards of Practice and Blind Bidding Policy. If any sections have a “YES” answer, provide all details below. This will be kept confidential.Your NameYour NameYour NameYour NameWORK EXPERIENCE VERIFICATION - MUST BE SIGNED BY A SUPERVISOR/MANAGERNRRTS will obtain your supervisor's signature on your behalf if your supervisor is not immediately available. Please complete the information. Supervisor's Name* First Last Supervisor Title*Supervisor's Email* Supervisor's Phone*Does the registrant have supervisory or management responsibility?* Yes No What % of his/her time is spent on patient care and service delivery?*A background check has been performed on this employee* Yes No Restriction of employment resulted from Background check* Yes No If YES, provide Detail with dates and restrictions noted below. This will be kept confidential.*Supervisor's SignatureThis should be signed by a supervisor. If your supervisor is not available, NRRTS will obtain the signature.Your NameYour NameYour NameYour NameRenewal & Reinstatement Fee in USD* Price: Ready to Pay?Clicking the Submit Button below will open a secure form into which you will enter your credit card information for payment. Thank you.
