Application for Certified Brain Injury Specialist Examination/Training

Application for Certified Brain Injury Specialist Examination/Training

Please type or print neatly and mail completed application to: BIANC, PO Box 97984, Raleigh, NC 27624

NAME:

______

LAST FIRST MI CREDENTIALS

ADDRESS: ______

STREET ADDRESSAPT #

______

CITYSTATEZIP

PHONE: (______) ______EMAIL: ______

PRESENT EMPLOYER: ______

BUSINESS ADDRESS ______

STREET ADDRESSSUITE #

______

CITYSTATE ZIP

______

BUSINESS PHONEWORK EMAIL

SUPERVISOR: ______SUPERVISOR PHONE: (______) ______

SUPERVISOR EMAIL: ______FAX: (______) ______

(Please be sure supervisor email is legible as an email will be sent to supervisor to verify employment)

WHAT IS YOUR CURRENT JOB TITLE? ______

TYPE OF FACILITY WHERE YOU PRESENTLY WORK:

_____HOSPTIAL ______REHABILITATION/SUB-ACUTE _____POST-ACUTE/COMMUNITY BASED

_____ACADEMIC/EDUCATIONAL/VOCATIONAL ______OTHER______

BRIEFLY DESCRIBE THE ORGANIZATION’S FUNCTIONS______

______

AVERAGE NUMBER OF PEOPLE WITH BRAIN INJURY SERVED PER YEAR:

____1-10 ___ 11-25 _____ 26-50 _____ 51-100 ____OVER 100

NUMBER OF DIRECT CONTACT HOURS WITH PERSONS WITH BRAIN INJURY IN THE PAST THREE YEARS (500 is the minimum to qualify for the CBIS certification) ______

EMPLOYMENT STATUS (DURING THE LAST 12 MONTHS)

____FULL TIME (30+/WEEK) ____PART TIME (<30/WEEK)_____OTHER (EXPLAIN______)

DESCRIBE THE NATURE OF YOUR CONTACT WITH PERSONS WITH BRAIN INJURY______

______

______

HOW MANY YEARS HAVE YOU WORKED IN THE FIELD OF BRAIN INJURY?______

EDUCATIONAL BACKGROUND: ______

HIGHEST EARNED ACADEMIC DEGREE

____ HIGH SCHOOL/GED_____ ASSOCIATES ______BACHELOR’S

____ MASTER’S______DOCTORATE

______NO DEGREE, BUT TAKEN COLLEGE COURSES

DEGREE TITLE: ______

NAME OF INSTITUTION OF HIGHEST DEGREE: ______

GRADUATION DATE: ______

OTHER SPECIALTY CERTIFICATION(S) OR TRAINING:

MEMBERSHIP IN PROFESSIONAL ORGANIZATIONS OR OTHER AFFILIATIONS:

Your name as you wish it to appear on the certificate and in the online list.

If you do not wish your name to be listed online, please email your request to

______

(PLEASE PRINT)

HOW DID YOU HEAR ABOUT THE ACADEMY OF CERTIFIED BRAIN INJURY SPECIALISTS? (IF IN A PUBLICATION, PLEASE SPECIFY)______

______

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 (

______

Signature Date

Ethics Statement

By submitting this application, I agree to abide by the ethics policy posted on the ACBIS website (

PLEASE MAIL COMPLETED APPLICATION TO: BIANC, PO BOX 97984, RALEIGH, NC 27624

Payment for CBIS class: $400 (check to BIANC should be included with application)

Please email your resume to: (We need an electronic copy)

Call 919-833-9634 or Susan Fewell at 919-618-3003 if you have questions or to reserve a place for an upcoming training class. Go to the CBIS page on our BIANC website for dates or other info: