CIC Application Fill out this 2-minute application below and we’ll be in touch. Country*United StatesAustraliaAustriaBelgiumBrazilCanadaCyprusEl SalvadorFinlandFranceGermanyGreeceGuamIndiaIrelandItalyJapanLiechtensteinLuxembourgMaltaMexicoNetherlandsNew ZealandNorwayPolandPuerto RicoSouth AfricaSpainSwedenSwitzerlandUnited Arab EmiratesUnited KingdomZimbabweIf your country is not listed you are not eligible for the CIC program.Name* First Last Title*Eligible Professions in the US: MD, DO, PhD/PsyD, PA, NP. If your title is not listed, you are not eligible for the CIC program. MDDOPANPPhDPsyDTitle*Eligible Professions Outside US: Any healthcare provider outside of the US who is qualified to manage concussions may apply.Email* Name of Organization/Clinic*Address* Street Address Address Line 2 City ZIP / Postal Code State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificThis field is hidden when viewing the formNoState - HiddenProvince / Region*AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukonPhone number where you can be reached*Are you a current ImPACT Applications customer, or are you affiliated with an organization that utilizes ImPACT Applications?* Yes No This field is hidden when viewing the formSend me information on training programs to build my multi-disciplinary concussion management team. Yes We reserve the right of sending periodic communications from ImPACT Applications.This field is hidden when viewing the formUser ID BACK TO PROGRAM INFORMATION You need to login to access the CIC application. Login BACK TO PROGRAM INFORMATION