Certification Transfer Form

Transfer of Certification Request Form
Inspector Name*

First NameLast Name
Employer currently named on Certificate*
Certification Level*

Level 1: In-HouseLevel 2: In-HouseLevel 1: ProfessionalLevel 2: ProfessionalSupervisor Endorsement
Certification Expiration Date*

MonthDayYear
Date
Certification #*
Ending Date with the Employer listed on current Certificate*

MonthDayYear
Date
REQUEST TO TRANSFER TO THE EMPLOYER LISTED BELOW
Start Date with New Employer*

MonthDayYear
Date
New Employer Business Name*
Best Phone Number to Reach You*

Area CodePhone Number
E-mail*
Best E-mail to Reach You
New Employer Mailing Address*

Street Address or PO Box

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Supervisor Name*
Supervisor Phone*

Area CodePhone Number
Supervisor Attestation from new employer.*

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Transfer of Certification $125.00

Total $0.00
Terms and Conditions: Should I terminate my employment with the company named on my ACCT Inspector Certification card, I agree to provide ACCT with an updated Certificate of Insurance within 30 days naming my new employer. Under penalty of law, I attest to the truth of these statements and any updated supporting documents. I understand that any misrepresentation will subject me to disciplinary action by ACCT including but not limited to revocation of my Inspector Certification.
I agree to the terms and conditions.
Should be Empty:

Transfer of Certification Request Form