IBC Recertification Application

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:
Name (as you want on your certificate)
Other last names you have used:
Certificate Number:
Certificate Expiration

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Home Address

Street Address

Street Address Line 2

CityState

Zip Code
Personal Email
example@example.com
Personal Phone

Area CodePhone Number
Current Employer
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Email:
example@example.com
Employer Phone

Area CodePhone Number
Have you ever had any credential (i.e. license, certification, endorsement, etc.) revoked, suspended or sanctioned?
If yes, please explain what credential, when, where, why, and current status of the credential below. If no, please skip to the next section.
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.

Distance Learning/Non-IBC Approved Trainings ($15/per training)

Rows	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

IBC Approved Trainings

Rows	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

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.

Rows	No. of Trainings	No. of Clock Hours
Ethics (6 hrs. required) IBC Approved
Ethics (6 hrs. required) Non-IBC Approved
Non-IBC Approved Relevant Education
IBC Approved Relevant Education

How will you be paying:
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.

Recertification Payment Information:

PRS Recertification$51.75

2-year Recertification

Late Fee$10.35

(1-45 days late)

CEU Approval Fee$15.53

CEU Approval Fee $15/ea. non-IBC approved cont. ed training

Quantity

Printed Certificate$10.35

Printed Certificate mailed to you.

Total $0.00

Debit or Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year

Attest: I am attesting that all information above is correct and accurate.
Attach any necessary documents

Upload a File

Cancelof
*Please note: The print option is provided for your personal records only. Recertification applications must be submitted through the online portal to be processed. Applications mailed or emailed to the office will not be accepted. Please refer to the IBC Handbook for additional recertification policies and procedures.
Should be Empty:

IBC Recertification Application

Professional Development Documentation

Recertification Payment Information: