This form is used to report job experience for credit in the Kentucky Public Human Resources Association public personnel administrator certification program. Candidates for certification should be familiar with the official guidelines and standards of the program before completing the form. Copies of the guidelines may be acquired by contacting Elizabeth Schepens at This form must be submitted by March 30th this year, for credit earned during the preceding calendar year (January 1 - December 31, 2017).
If yes, please attach a copy if you did not send one last year or if your position or duties have changed.   
If "no", please explain how and by whom your duties are defined:
1. Enter total of all hours from Section 6-A-9 and Section 6-B-7 above
2. Enter total hours from Section 5
If line C-1 and line C-2 are different, attach explanation for difference.
3. a) Enter hours from section 6-A-9 here
3. b) Enter hours from Section 5 here
3. c) Divide line C-3-a by line C-3-b and enter result here
Attach any HR related education you attended during the calendar year covered by this report (for years 2015 and after) that was not provided by KPHRA that you would like to submit for consideration to be counted toward your certification. Up to 35 hours for certification or 25 hours for recertification may be counted for HR related education not provided by KPHRA.
For each educational session, please list the following:
Date, Number of Hours, Session name and topic(s) covered, the presenter, the host organization and location. Documentation or other materials that explain, show, or describe the education session is required.
The Certification Committee will review your request and has final authority to approve or deny granting KPHRA credit for education received from outside sources.
Attach your job description here.

Attach back up verification here.
I understand that any willful misrepresentation of my work or educational experience may result in removal from the certification program and revocation of certification if it has already been granted. Typing your name below will serve as your signature.
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