Request for Reinstatement Form v.2

NOTE: A REQUEST FOR REINSTATEMENT MUST BE SUBMITTED FOR EACH CERTIFICATION SUSPENDED OR REVOKED.

**This form is for use by Regular Certified Members Only!**

Other member categories must email membership@theiic.org for instructions.

Fees Due: $125 Reinstatement Fee + $175 Annual Member Fee

Total Due: $300 (each certification reinstated)

Special Instructions

For your convenience, Autofill will keep all your input data for 24 hours if you must leave the form before completing. You must use the same browser in order to pick up the form where you left off!

Date of Request*

MonthDayYear

Certification Reinstatement Requested*

NOTE - Separate applications required for each certification reinstatement requested

Salutation*

First Name*

Middle Name

Last Name*

Member/Certificate # listed on your certificate or membership card.*

For multiple certifications input each separated by comma

Personal Phone Number*

Country CodeArea CodePhone Number

Home/Local Residence Address for Mailing*

Street Address

P.O. Box or Suite #(if any)

CityState / Province

Postal / Zip Code(if you are applying from a country that does not utilize postal codes or zip codes, Type "N/A" or NONE. This field is NOT for P.O. Boxes)Country

Personal E-mail*

CURRENT EMPLOYER/BUSINESS MAILING INFORMATION

**Note: If unemployed, input "unemployed" in the Employer Name field & N/A in any additional required fields**

Employer Name*

Department*

Job Title*

Business Address*

Street Address

P.O. Box or Suite# (if any)

CityState / Province

Postal / Zip Code (if you are applying from a country that does not utilize postal codes or zip codes, type "N/A" or NONE. This field is NOT for P.O. Boxes)Country

Business Phone Number*

Country CodeArea CodePhone Number

Business E-Mail*

example@example.com

Preferred Mailing Address*

PersonalBusiness

Preferred E-Mail Address (used for Members Only log-in)*

PersonalBusiness

Have you ever been convicted of a felony?*

YesNo

If Yes, please explain: (limit 100 words)

0/100

Certifications Held*

CICACCS

Termination Status*

Certification Suspended (less than 3 years non-membership)Certification Revoked (more than 3 years non-membership)Unknown

READ AND CLICK BELOW YOUR UNDERSTANDING AND AGREEMENT WITH THE FOLLOWING:

*I hereby request reinstatement of my membership in The IIC as well as the certification(s) noted above. I understand that reinstatement is a one-time event and that any failure to maintain my membership and certification(s) in the future will result in permanent revocation without reinstatement.

*I understand that i must be in compliance with The IIC's Professional Standards, Ethics Policy and CPE Policy.

*I confirm that I have not been convicted of any felony to date that has not been reported by me to the IIC.

*I understand that I will not be reissued a new certificate and that I may receive a new certificate if needed by requesting a replacement certificate (non-framed) via the IIC website at a fee.

*I agree to provide an updated Change-Request form to ensure my profile including mailing and emailing addresses are current (available at the Member's Page at www.theiic.org).

Check agreement with reinstatement terms.*

I have read and agree with all the terms and conditions regarding reinstatement and wish to proceed with the reinstatement process noted above.

Please include anything you wish to add to your application here (LIMIT 100 WORDS):

0/100

Applicant Electronic Signature

WARNING: UNSIGNED APPLICATIONS WILL BE REJECTED

Please type your name in the box below followed by /es/ to represent your signature*

Note: you will be notified within 48 hours by email(excluding weekends and holidays) of the status of your request with instructions for follow-up if necessary.

IMPORTANT: Both Reinstatement Fee AND Annual Dues must be paid in order for Reinstatement Request to be processed.

NOTE: You MUST click the PRINT button on the “Submit and Pay” tab to provide a hardcopy of this form. You must do this before clicking the SUBMIT button since you may not be able to print out a copy of the form for your records once you click the SUBMIT button.

Method of Payment*

Credit CardCheck or Money Order to be sent by applicant

Note: Be advised that Affinipay is providing services as TheIIC's CC bank/vendor. If Affinipay does not operate in your country, contact membership@theiic.org immediately for a link to use an alternative CC vendor. No action on your application will be considered before receipt of payment in full.

Check or Money Order*

Reinstatement Fee + Annual Certification Fee= $300.00

NOTE: You MUST click the PRINT button on the “Submit and Pay” tab to provide a hardcopy of this form. You must do this before clicking the SUBMIT button since you may not be able to print out a copy of the form for your records once you click the SUBMIT button.

Manual Payment

If paying by Check or Money Order, Click Print Form button below to print out a copy for your records, then click the Submit Button to send your completed application to the IIC.

Send your Check or Money Order (payble on a US BANK ONLY in US DOLLARS) in the amount of $300.00 to:

Institute for Internal Controls Inc.

Attn: Nominations Committee

109 Mullen Drive

Sicklerville, NJ 08081

USA

Note-no reinstatement will be considered before the receipt of full payment.

TheIIC Request for Reinstatement Form

Manual Payment