IBC Recertification Application

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.
CADCIADCIAADCCCJPCPS/ACPSPRSCTACGTCFPSSMHPSS
Name (as shown on your certificate)*
Certificate Number:
Certificate Expiration:
Home Address

Street Address

Street Address Line 2

CityState

Zip Code
Personal Email
example@example.com
Personal Phone

Area CodePhone Number
Reason for requesting Inactive Status:
Last Date working in the Substance Abuse Field

MonthDayYear
Date
Approximate date for returning to Substance Abuse Field

MonthDayYear
Date
OnlineCheck
All pricing below includes the processing fee charged by our online payment vendor. These fees cannot be adjusted, and we are unable to accept payments over the phone. Payments may be made online or by mailing a check.

Inactive Fee Payment Information:

Inactive Fee$87.98

Inactive Fee for 1 year

Late Fee$51.75

(1-45 days late)

Total $0.00

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.
Attach any necessary documents

Upload a File

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Attest: I am attesting that all information above is correct and accurate.

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IBC Inactive Application