Appeal Submission Form

Appeal Submission Form
What is the date of the issue that you are appealing? If you are appealing a decision of the ABC, what is the postmark or the e-mail date stamp on the notification that you received. *

Month Day Year
Date
Current Date

Month Day Year
Date
Elapsed Days
Appeals must be filed within 60 days. Are you filing the appeal within 60 days or less? *

Yes No
Appeals must be received within 60 days of the date of the incident that you are appealing or within 60 days of the postmark date or e-mail date stamp of the notification that you received. You have indicated that your appeal does not meet this requirement. You may continue to complete the form, however the appeal will likely be denied because it does not meet the submission deadline.
Do you wish to continue to file your appeal? *

Yes No
Thank you!
Name of Appellant *

First Name Last Name
Applicant/Certificant Number *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email *
example@example.com
Phone Number *
Please enter a valid phone number.
Type of Appeal: *
If Other, please explain *
Appeals Chair Acceptance of appeal *
Appeals Chair Name
RESCORE REQUESTS ONLY
Date of Exam Sitting *

Month Day Year
Date
Examination Taken *
Date Rescore Completed *

Month Day Year
Date
Date Pass/Fail Confirmed with EC Chair *

Month Day Year
Date
Did P/F Status Change?

Yes No
Possible Scoring Error?

Yes No
If applicalbe, QR#
How were the rescore materials disposed of?

Removed from Sync Returned to Registrar via Certified Mail
Date of Destruction by Registrar

Month Day Year
Date
Comments
RECERTIFICATION APPEALS ONLY:
If you have more than one activity that you appealing, please make clear the points you are appealing for each activity. You may use the "Description of Appeal" box to ensure we are clear on the points you are appealing.
Sections to be addressed
Points requested
Description of the appeal
Do you need additional information to process the appeal?

Yes No
Request for Additional Information
Date 09-0903T was Sent

Month Day Year
Date
Date read from e-mail receipt:

Month Day Year
Date
Date Information was Received

Month Day Year
Date
Elapsed time, additional information must be received within 45 days of the date stamp of the e-mail communication
Was the additional information received within the required time frame?

Yes No
Was additional information needed from a member of ABC (BoD, TSM, Registrar, EC, etc.)?

Yes No
Additional information was requested from:
Date Information was requested from ABC

Month Day Year
Date
Date Information was received from ABC

Month Day Year
Date
What is the date the last piece of additional information was received by Appeals Committee?

Month Day Year
Date
Was the appeal reviewed by the committee?

Yes No
Appeal Committee Review
Names of Committee Members
Date Information was sent to the committee

Month Day Year
Date
Date the recommendation was received by the Chair

Month Day Year
Date
Recommended Disposition
Date 09-0904T was sent to Appellant

Month Day Year
Date
Date read from e-mail receipt

Month Day Year
Date
Time elapsed for Appellant Notification (No additional Information Received)
Appeals Chair should notify appellant within 60 days of appeal
Time elapsed for Appellant Notification (Additional Information Received)
Appeals Chari should notify appellant within 60 days of last received information.
Was the appellant notified within the required time frame?

Yes No
Did the appellant appeal to the Board of Directors?

Yes No
Appeal to BoD
Date received by President

Month Day Year
Date
Date of postmark or time stamp on BoD appeal notification

Month Day Year
Date
Time elapsed between 09-0904T and BoD appeal
Appeal must be postmarked withink 60 days of 09-0904T.
Was the appeal to the BoD received within the required time frame?

Yes No
Letter of acknowledgement sent

Month Day Year
Date
Date acknowledgement letter read from e-mail receipt

Month Day Year
Date
Was an in-person hearing requested?

Yes No
Date of Board Resolution

Month Day Year
Date
Was committee decision upheld?

Yes No
Date BoD Appeal 09-0904T Sent

Month Day Year
Date
Date read from e-mail receipt

Month Day Year
Date
Additional Comments
Should be Empty:

Appeal Submission Form

Thank you!

RESCORE REQUESTS ONLY

RECERTIFICATION APPEALS ONLY:

Request for Additional Information

Appeal Committee Review

Appeal to BoD