AHIP Application – All Levels AHIP Application Application Date(Required) MM slash DD slash YYYY Level for Which You Are ApplyingSelect Configuration…DistinguishedEmeritusMemberProvisional 1Provisional 2Provisional 3Provisional 4Provisional 5SeniorAHIP Status: Are you a … New Academy Applicant Current Academy Member Renewing at a Higher Level Current Academy Member Renewing at the Same Level This field is hidden when viewing the formRenewal Status Current AHIP Level Configuration Current AHIP Dates Start Date End Date Portfolio Start Date MM slash DD slash YYYY Portfolio End Date MM slash DD slash YYYY Name(Required) First Last Email(Required) Current Job TitleIndicate or confirm your current job title. Job Title How did you hear about AHIP? / Renewing: Why are you renewing your credential?(Required)Certificate VerificationName (exactly as it should appear on your certificate)(Required)Address (where your certificate should be mailed)(Required) Institution Name and Library Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican 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 RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican 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 RicoQatarRomaniaRussian FederationRwandaRéunionSaint 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 TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Would you like employer notification of your approved AHIP status?(Required)Up to 2 notifications allowed. Yes No Current Supervisor InformationCurrent Supervisor's Name #1Indicate or confirm your current supervisor’s name. Current Supervisor's Title #1Indicate or confirm your current supervisor’s title. Supervisor Email #1May we contact your supervisor should we need to verify information? Supervisor's Institution #1Supervisor's Address #1 Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican 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 RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican 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 RicoQatarRomaniaRussian FederationRwandaRéunionSaint 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 TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Current Supervisor's Name #2Indicate or confirm your current supervisor’s name.Current Supervisor's Title #2Indicate or confirm your current supervisor’s title.Supervisor Email #2May we contact your supervisor should we need to verify information? Supervisor's Institution #2Supervisor's Address #2 Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican 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 RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican 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 RicoQatarRomaniaRussian FederationRwandaRéunionSaint 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 TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country AHIP ProvisionalAcademic PreparationAcademic Preparation School Type(Required)Specify one of the following.ALA-accredited Master's degreeMaster's level degree in library and information studies accredited or recognized by the appropriate national body of another countrySixth year certificate or a doctoral degree from a school that offers an ALA-accredited master's degreeMaster's or doctoral degree in any field with documented coursework in all of the six MLA Competencies for Lifelong Learning and Professional SuccessDiplomaPlease upload a copy of your diploma or transcript for master’s degreeMax. file size: 256 MB. Competency InstructionPlease state the course name, who sponsored the course and the points claimed for the competency it satisfies. You must submit 8 points for each competency. You may use one course for up to two competencies.Course NameSponsored InstructionC1C2C3C4C5C6 Add RemoveCompetency JustificationPlease upload the required documentation Drop files here or Select files Max. file size: 256 MB, Max. files: 12. Professional Work ExperienceYears of Professional Work Experience (this section is only required for new or higher level applications)Indicate or confirm the total number of years of work experience as a librarian since receiving your master’s degree. If you have more than 5 years of professional librarianship experience (any field) post Master’s degree, you are ineligible for Provisional level.Job DescriptionPlease upload your current job description Drop files here or Select files Accepted file types: docx, doc, pdf, Max. file size: 256 MB, Max. files: 4. CV or resumePlease upload your current CV or resume Drop files here or Select files Accepted file types: docx, doc, pdf, Max. file size: 256 MB, Max. files: 4. Competencies Self-AssessmentEnter your Provisional Self-Review of Professional Competencies Skill LevelUse the results from your Competencies Self-Assessment to complete this area. Skill Level Importance to Career Areas for Attention Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Upload your completed MEDLIB-Ed Competencies Self-AssessmentMax. file size: 256 MB. AHIP MentorMLA will assign you a mentor to help guide your studies. If you know one or two potential mentors with whom you would like to work, please list them here: Potential Mentor Name #1Mentor Email #1 Potential Mentor Name #2Mentor Email #2 This field is hidden when viewing the formAHIP Higher LevelsAcademic Preparation (new applications only)The required academic preparation for all levels of membership is one of the following: an ALA-accredited Master’s degree, OR a master’s level degree in library and information studies accredited or recognized by the appropriate national body of another country, OR a sixth year certificate or a doctoral degree from a school that offers an ALA-accredited master’s degree, OR a master’s or doctoral degree in any field with documented coursework in all of the six MLA Competencies for Lifelong Learning and Professional Success For case 4 only, you must justify a minimum of eight contact hours of sponsored instruction or coursework in each of the six core competencies. You may count one class for up to two competencies if it applies. You will be asked the following: Sponsored Instruction Required Documentation Continuing Education course preapproved for MLA credit A copy/Copies of MLA CE certificate(s) Continuing Education course not preapproved for MLA credit A copy of certificate or letter of completion plus a copy of the course syllabus Academic course work A copy of transcript plus a copy of the course syllabus Academic Preparation School TypeSpecify one of the following.ALA-accredited Master's degreeMaster's level degree in library and information studies accredited or recognized by the appropriate national body of another countrySixth year certificate or a doctoral degree from a school that offers an ALA-accredited master's degreeMaster's or doctoral degree in any field with documented coursework in all of the six MLA Competencies for Lifelong Learning and Professional SuccessDiploma (required only for new and higher level applicants)Please upload a copy of your diploma or transcript for master’s degree Drop files here or Select files Accepted file types: pdf, png, jpg, docx, Max. file size: 256 MB. Competency Instruction(Required)Please state the course name, who sponsored the course and the points claimed for the competency it satisfies. You must submit 8 points for each competency. You may use one course for up to two competencies.Course NameSponsoring Association or InstitutionC1C2C3C4C5C6 Add RemoveCompetency Justification(Required)Please upload the required documentation/transcript Drop files here or Select files Accepted file types: pdf, jpg, png, docx, Max. file size: 256 MB, Max. files: 12. Professional Work ExperienceYears of Professional Work ExperienceIndicate or confirm the total number of years of work experience as a librarian since receiving your master’s degree.Job Description (required only for new and higher level applicants)Accepted file types: jpg, png, pdf, docx, Max. file size: 256 MB, Max. files: 2. Drop files here or Select files Accepted file types: jpg, png, pdf, docx, Max. file size: 256 MB, Max. files: 2. CV (required only for new and higher level applicants)Accepted file types: jpg, png, pdf, docx, Max. file size: 256 MB, Max. files: 2. Drop files here or Select files Max. file size: 256 MB, Max. files: 2. Individual Professional AccomplishmentsTally FormPlease bypass this section IF: 1. You are a current AHIP member renewing at the SAME level – Member, Senior, Distinguished 2. You are a new Provisional applicant.; YOU MUST COMPLETE THIS SECTION and upload documentation IF 1. You are a new AHIP applicant applying at the Member, Senior or Distinguished level 2. You are a current AHIP member applying for a higher level. 3. You are a renewing Provisional member. Activity Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. DocumentationDocument the activity listed in support of your AHIP application (required only for new and higher level applications)If you are a new AHIP applicant or renewing at a higher level, please combine and upload your documentation here, in the same order as your tally form. We suggest uploading as few documents as possible; 5 maximum files allowed. Drop files here or Select files Accepted file types: pdf, jpg, png, docx, Max. file size: 256 MB, Max. files: 5. Emeritus LevelOriginal Academy Start DateEmeritus applicants must have at least 10 years of AHIP membership at time of retirement. Applicants must also be a current AHIP member. Start Date This field is hidden when viewing the formNumber of years for AHIP Membership Retirement Date MM slash DD slash YYYY This field is hidden when viewing the formAHIP Provisional RenewalRenewal Dates Renewal Start Date Renewal End Date Annual Renewal ActivitySponsored LearningMust submit at least 8 points of CE activity accomplished during the renewal period. Use the “+” sign to add more rows.Area of CompetencyCourse NameSponsor/InstitutionDatePoints Claimed Add RemoveProfessional Activity (ex. publishing, editing, meeting participation, professional association service)Must submit at least 5 points of professional activity accomplished during the renewal periodActivityActivity Date(s)Points Claimed Add RemoveRenwal DocumentationAnnual Provisional Renewal DocumentationDocument the activity listed in support of your annual Provisional renewal application Drop files here or Select files Accepted file types: pdf, docx, doc, Max. file size: 256 MB. Mentor InformationHave you met with your mentor to verify your renewal? Yes No If you have not met, why?AHIP Mentor nameAHIP Mentor Email This field is hidden when viewing the formFinal Reviewer Email This field is hidden when viewing the formTerm – Start Date and End Date
