IBC Recertification Application
Application and fees are due to IBC on or before your date of expiration or the late fee will be due. Please note this page does not save, so if you navigate away from it your work will be lost. At the end of the application you will have the opportunity to print the file prior to submitting it.
Credential You Are Recertifying:
*
PRS
Name (as you want on your certificate)
*
Other last names you have used:
Certificate Number:
*
Certificate Expiration
*
-
Month
-
Day
Year
Date
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
Current Employer
Employer Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Business Email:
example@example.com
Employer Phone
-
Area Code
Phone Number
Have you ever had any credential (i.e. license, certification, endorsement, etc.) revoked, suspended or sanctioned?
Yes
No
If yes, please explain what credential, when, where, why, and current status of the credential below. If no, please skip to the next section.
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Professional Development Documentation
You do NOT need to submit copies of your certificate of completions listed below, however, be sure to keep copies of your certificates in case your recertification is audited by IBC. Application and fees are due to IBC on or before your date of expiration or the late fee will be due. Reminder: professional development classes are required to have taken place during certification period--anything prior to the certification date will not be approved.
IBC Approved Trainings
Training Date
Title of Training
Ethics #
Relevant Ed #
IBC Training
IBC Training
IBC Training
IBC Training
IBC Training
IBC Training
IBC Training
IBC Training
IBC Training
IBC Training
IBC Training
IBC Training
IBC Training
Distance Learning/Non-IBC Approved Trainings
Training Date
Title of Training
Ethics #
Relevant Ed #
Non IBC Training
Non IBC Training
Non IBC Training
Non IBC Training
Non IBC Training
Non IBC Training
Non IBC Training
Non IBC Training
Non IBC Training
Non IBC Training
Non IBC Training
Non IBC Training
Non IBC Training
Total number of professional development hours submitted, as recorded below. A minimum of 20 hours required. IBC will reach out if we do not agree with the totals.
Number of Clock Hours
Ethics (6 hrs. required)
Relevant Education
Fees
Total Amount:
Recertification Fee $50
Late Fee $10 (if 1-45 days late)
CEU Approval Fee $15.00/ea.Non IBC approved cont. ed training
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
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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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