IBC Inactive Application
Be sure to carefully review the eligibility requirements for requesting Inactive Status (in Counselor handbook) as well as reactivating the certification once you return to the field.
Credential to become inactive:
CADC
IADC
IAADC
CCJP
CPS/ACPS
PRS
CTA
CGTC
FPSS
MHPSS
Name (as shown on your certificate)
*
Certificate Number:
Certificate Expiration:
Home Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Personal Email
example@example.com
Personal Phone
-
Area Code
Phone Number
Reason for requesting Inactive Status:
Last Date working in the Substance Abuse Field
-
Month
-
Day
Year
Date
Approximate date for returning to Substance Abuse Field
-
Month
-
Day
Year
Date
Back
Next
Save
Fees
Total Amount:
Inactive Fee (one year) $85.00
Late Fee (if 1-45 days late) $50.00
TOTAL AMOUNT DUE:
How will you be paying:
Online
Check
Attest: I am attesting that all information above is correct and accurate.
Attach any necessary documents
Upload a File
Cancel
of
Submitting Application
Please note you can save the form for editing OR you can submit the form. IBC cannot view and/or review the form until it has been submitted. If the form is submitted correctly you should get a thank you page that alerts you that the form has been successfully submitted.
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