ALTCQI 2026 Renewal Form (Fillable)

Back to CQRMS Certification

P.O. Box 247, 1655 N McFarland Blvd

Tuscaloosa, AL 35406

[email protected]

ALTCQI 2026 CQRMS RENEWAL FORM

Certified Quality and Risk Management Specialist — Renewal Fee: $100.00

Personal Information

First Name*

Last Name*

Credentials / Title (e.g. RN, NHA, LNHA)

Contact Information

Mailing Address*

City*

State*

ZIP Code*

Phone Number*

Email Address*

Certification Details

CQRMS Certification Number*

Certification Expiration Date*

Employer / Facility Information

Facility / Employer Name

Facility City

State

ZIP Code

Renewal Fee Payment — $100.00

Preferred Payment Method*

Pay via PayPal: Scan the QR code with your phone camera, or visit:
paypal.com/qrcodes/managed/fec2717d-a4f3-4810-879e-8938b8bea763
Pay by Check: Make payable to ALTCQI and mail to P.O. Box 247, 1655 N McFarland Blvd, Tuscaloosa, AL 35406

Certification & Signature

I certify that the information provided on this form is accurate and complete. I understand that my CQRMS designation will be renewed upon receipt and processing of this form and the required renewal fee of $100.00.

Signature

Date

Alliance for Long-Term Care Quality Improvement (ALTCQI) · altcqi.org

Questions? [email protected]

2026 Renewal Form

Submit Online Instead