Recertification Online Form If you are a human and are seeing this field, please leave it blank. Fields marked with an * are required First Name * Last Name * Address * Apt No. City * State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code * Email * Phone Number Instructions When entering your phone number below, do not add the leading 1 digit. Examples: WRONG: 1 (555) XXX-XXXX CORRECT: (555) XXX-XXXX Phone * Date of Birth * *IMPORTANT* Submitting this online form is only one half of the online recertification submission process. You will need to call:1-877-262-9259 to provide your NAME and SOCIAL SECURITY NUMBER. This information will be matched to the information you have already submitted online. This extra step is provided as an extra layer of security in the protection of your personal information. If you do not call and complete your submission, we will be unable to process your request.