30 Day Extension Request Form

30 Day Extension Request Form

Fee - Free
MHACBO allows counselors a free 30 day extension for a credential during each renewal period.

Candidate Status cannot be extended through this form. If you are trying to extend your Candidate Status, please contact mhacbo@mhacbo.org
Full Name *

First Name Last Name
E-mail *
Certification Number
Your certification number can be found on our online registry at www.accbo.com/registry
Home Phone Number *

Area Code Phone Number
Work Phone Number *

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Reason for requesting extension
Should be Empty: