Certification Inactive Status Form

Which credential are you renewing?*

DBIA™
Assoc. DBIA™

Certification ID #*

Date Certified*

Renewal Due Date*

Please provide full contact information for our records.

Last Name*

First Name*

Title

Company

Address*

Street Address Address Line 2 City State ZIP Code

Email*

Phone*

Applicable Programs and Activities. 24 Continuing Education Hours required. Please provide proof of attendance.*

Please list design-build specific activities here — 12 hours minimum required

Program/Activity Name	Date (or Range)	Sponsoring Organization	# of Credit Hours (24 hours of continuing education required)

Total hours of design-build hours*

Related industry organizations that provide value as a design-build professional, i.e., AIA, AGC, ACEC, etc, or in-house structured education offerings (12 hours maximum). Please provide proof of attendance.

Program/Activity Name	Date (or Range)	Sponsoring Organization	# of Credit Hours (24 hours of continuing education required)

Total hours of industry-related training*

Total hours of Continuing Education (24 hours minimum)*

I certify that the information contained on this renewal is true and accurate, and understand that the Design -Build Certification Board (DBCB) reserves the right to conduct an audit requiring additional proof of information submitted. I also understand that the DBCB reserves the right to reject credit that it deems not applicable to my work as a design-build professional. If any of this information is determined to be false, the DBCB reserves the right to revoke my DBIA™ or Assoc. DBIA™ certification. I further understand that by renewing the DBIA™ or Assoc. DBIA™ credential that I am affirming my commitment to abide by and uphold the principles of the DBIA Code of Professional Conduct.

DBIA Code of Professional Conduct*

Please check here to confirm that you have read and undertand the DBIA Code of Professional Conduct.

Select One:*

DBIA Member — $50.00
Non-Member — $150.00

Payment Method*

Check (Made payable to DBIA)
Credit Card

Credit Card Information*

Visa
MasterCard
AmEx

Card Number	VCode	Expiration Date

Certification Inactive Status Form

Certification Renewal Form