EQIT Duplicate Certificate Request Form

EQIT Duplicate Certificate Request Form

Please complete all areas of the form and we will send you a new EQIT certificate within 2 weeks.
Name on Original EQIT Certificate:

First NameMiddle NameLast Name
Address Where EQIT Certificate will be sent:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
PDIS Account E-mail
Mobile Number

Area CodePhone Number
Approximate date EQIT course was completed:

MonthDayYear
Date
Early Childhood Council, County, or City where EQIT took place:
Names of EQIT Instructors:
Reason for Duplicate EQIT Certificate Request:
Should be Empty: