Contact Information
First Name:
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Credentials:
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Apt. #
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Present Employer
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Group Membership
If you are a member of a group making application, please contact your Group Administrator for your Group Number and enter it here:
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Additional Information
Supervised employment, academic internship, or professional licensure is required for this application. Please see http://acbis.pro/level1.html for complete requirements. Type of facility in which you presently work:  Hospital  Rehabilitation/Sub-acute Rehab  Post-acute/Community Based  Academic/Educational/Vocational  Other Explain: How many years have you been working in that setting? What is your current title? Average number of people with Brain Injury served per year:  1-10  11-25  26-50  51-100  over 100 Current Employment Status:  Full Time (30+ hours per week)  Part Time (less than 30 hours per week)  Other (please explain below) Explain: How many years have you been working in the field of brain injury? In what capacity have you worked? Be specific. Education (highest earned academic degree):  High School/GED  Associates  Bachelor's  Master's  Doctorate  no degree, but taken college courses Name of Institution of Highest Degree: Graduation Date: Degree Title: Other Specialty Certification(s) or Training: Membership in Professional Organizations or Other Affiliations: How did you hear about ACBIS? Colleague Conference Mailing       If Mailing, enter four-digit code on mailing address label: Publication       If Publication, please specify: Your name as you wish it to appear on the certificate and in our online list; if you do not wish your name to be listed online, please email your request to acbis@biausa.org: I hereby apply to be a candidate as a Certified Brain Injury Specialist and verify that all the information is correct. By submitting this application, I also agree to be bound by all policies and procedures set forth by the ACBIS Guidelines (www.acbis.pro). Ethics Statement By submitting this renewal application, I agree to abide by the ethics policy posted on the ACBIS website. Testing Accomodations will be made in accordance with the American with Disabilities Act. The disability must be documented and the applicant must request the accomodations in writing. Payment for this application must be received before the application will be processed. The fee structure is outlined at http://www.acbis.pro/testing.html. Payment options: Pay by credit card Pay by check
If you choose "Pay by credit card", you will be directed to the Brain Injury Association of America Marketplace.  You are also required to (1) submit your resume and employment verification - as well as a copy of your payment receipt - to your Group Administrator if you are a member of a group or (2) mail or fax your resume and employment verification to the ACBIS coordinator at the Brain Injury Association of America, if you are an individual applicant. If you choose "Pay by check", you will be directed to a statement page which should be printed and (1) submitted, along with your payment, resume, and employment verification, to your Group Administrator, if you are a member of a group, or (2) mailed to the ACBIS coordinator at the Brain Injury Association of America, if you are an individual applicant, along with your payment, resume, and employment verification. If you are an international applicant, please choose "pay by check" to generate your statement and call the Brain Injury Association of America at 703-761-0760, x620, for assistance with payment. Please note that the Essential Brain Injury Guide is available for a reduced price of $40.00 plus $6.00 shipping/handling with the submission of an application. The Guide is available in either payment option (it is listed in the BIAA Marketplace and on the statement).                                         Brain Injury Association of America/ACBIS                     1608 Spring Hill Road, Suite 110                     Vienna, VA  22182                     703-761-0750                     703-761-0755 (fax) Thank You!  Did you remember to fill out all the fields? Please click on the SEND button below to submit your application. Please click only ONCE.