Certification Reinstatement Request Form

Only requests for certifications that have lapsed for three (3) years or less will be considered.
Name
First Last
Title
Employee Name
Employee Address
Street Address Address Line 2 City State ZIP Code
Phone
Type of Credential
- DBIA™
- Assoc. DBIA™
Certification ID #
Year credential expired
Will be verified by DBIA National office
Do you understand that you must successfully pass the DBIA certification examination and that an additional exam fee sitting will be required?
- Yes
- No
I hereby apply for reinstatement of credential and will fulfill the requirements for Reinstatement as stated in the Certification Reinstatement Policy. I acknowledge that this request is granted only. I understand that my DBIA credential will not be retroactive and will start over from the date my request is and approved and I successfully pass the certification examination.
Employee Signature
Date
MM slash DD slash YYYY
Reinstatement Fee
- DBIA Member Fee – $200
- Non-Member Fee – $300
Reinstatement requirements must be met as outlined in the Certification Reinstatement Policy.