Request for Reinstatement Form v.2

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Date of Request* This field is required.

Date

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INSTRUCTIONS

NOTE: A REQUEST FOR REINSTATEMENT MUST BE SUBMITTED FOR EACH CERTIFICATION SUSPENDED OR REVOKED.

**This form is for use by Regular Certified Members Only!**

Other member categories must email membership@theiic.org for instructions.

Fees Due: $125 Reinstatement Fee + $175 Annual Member Fee

Total Due: $300 (each certification reinstated)

Special Instructions

For your convenience, Autofill will keep all your input data for 24 hours if you must leave the form before completing. You must use the same browser in order to pick up the form where you left off!

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Certification Reinstatement Requested* This field is required.

NOTE - Separate applications required for each certification reinstatement requested

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Salutation* This field is required.

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First Name* This field is required.

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Middle Name

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Last Name* This field is required.

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Member/Certificate # listed on your certificate or membership card.* This field is required.

For multiple certifications input each separated by comma

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Personal Phone Number* This field is required.

Country Code

Area Code

Phone Number

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Home/Local Residence Address for Mailing* This field is required.

Street Address

P.O. Box or Suite #(if any)

City

State / Province

Postal / Zip Code(if you are applying from a country that does not utilize postal codes or zip codes, Type "N/A" or NONE. This field is NOT for P.O. Boxes)

Country

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Personal E-mail* This field is required.

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CURRENT EMPLOYER/BUSINESS MAILING INFORMATION

**Note: If unemployed, input "unemployed" in the Employer Name field & N/A in any additional required fields**

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Employer Name* This field is required.

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Department* This field is required.

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Job Title* This field is required.

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Business Address* This field is required.

Street Address

P.O. Box or Suite# (if any)

City

State / Province

Postal / Zip Code (if you are applying from a country that does not utilize postal codes or zip codes, type "N/A" or NONE. This field is NOT for P.O. Boxes)

Country

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Business Phone Number* This field is required.

Country Code

Area Code

Phone Number

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Business E-Mail* This field is required.

example@example.com

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Preferred Mailing Address* This field is required.

Personal

Business

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Preferred E-Mail Address (used for Members Only log-in)* This field is required.Personal Email suggested to avoid delivery failure due to change of employment.

Personal

Business

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Have you ever been convicted of a felony?* This field is required.

Yes

No

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If Yes, please explain: (limit 100 words)

0/100

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Certifications Held* This field is required.

CICA

CCS

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Termination Status* This field is required.

Certification Suspended (less than 3 years non-membership)

Certification Revoked (more than 3 years non-membership)

Unknown

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READ AND CLICK BELOW YOUR UNDERSTANDING AND AGREEMENT WITH THE FOLLOWING:

*I hereby request reinstatement of my membership in The IIC as well as the certification(s) noted above. I understand that reinstatement is a one-time event and that any failure to maintain my membership and certification(s) in the future will result in permanent revocation without reinstatement.

*I understand that i must be in compliance with The IIC's Professional Standards, Ethics Policy and CPE Policy.

*I confirm that I have not been convicted of any felony to date that has not been reported by me to the IIC.

*I understand that I will not be reissued a new certificate and that I may receive a new certificate if needed by requesting a replacement certificate (non-framed) via the IIC website at a fee.

*I agree to provide an updated Change-Request form to ensure my profile including mailing and emailing addresses are current (available at the Member's Page at www.theiic.org).

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Check agreement with reinstatement terms.* This field is required.

I have read and agree with all the terms and conditions regarding reinstatement and wish to proceed with the reinstatement process noted above.

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Please include anything you wish to add to your application here (LIMIT 100 WORDS):

0/100

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Applicant Electronic Signature * This field is required.Type your full name, followed by /es/ to represent your electronic signature.

WARNING: UNSIGNED APPLICATIONS WILL BE REJECTED

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PAYING THE REQUIRED REINSTATEMENT FEES

Note: Reinstatement Fees are paid by Credit Card. Please be advised that Affinipay is providing services as TheIIC's Credit Card bank/vendor.

If Affinipay does not operate in your country, contact membership@theiic.org immediately for a link to use an alternative CC vendor. No action on your application will be considered before receipt of payment in full of all required fees.

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How to Pay

(1) Click Next below and then (2) choose Credit Card on Payment page and (3) click “Review and Submit" on the bottom right to review your applicaion for reinstatement. To pay, (4) click on submit to be directed to Affinipay to finalize the transaction. In the reference field enter the words Application for Reinstatement. A pdf copy of this form will be sent in a return email to you upon completion of the transaction.

IMPORTANT: Both Reinstatement Fee AND Annual Dues MUST be paid in order for Reinstatement Request to be processed.

You will be notified within 48 hours by email(excluding weekends and holidays) of the status of your request for reinstatement with instructions for follow-up if necessary.

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Payment* This field is required.Click on Credit Card to enter your card details and complete the transaction. All Required Fees must be paid in full before consideration of reinstatement can commence.

Credit Card