Expiration Date Change Form

By completing this form I authorize PCB to change the expiration date of the indicated credential(s) to that of my primary credential. In this way, recertification for both or all credentials may occur with the same application, and most or all of the same education (depending on the credential) can be utilized. I also acknowledge that I may be gaining time or losing time by the expiration date change.
I understand that changing an expiration date may possibly shorten the time I have to accrue continuing education, and no extensions of time or grace period will be granted. Recertification will be due on the new expiration date. (It may be beneficial to delay your date changes if you are in danger of not meeting your obligation of recertifying by the expiration date).
To determine your primary credential: look at your certificates and find your issue date. The credential you earned first, is your primary credential.
A new certificate(s) will be issued upon approval.

FEE: $25/credential to be changed

Professional Information & Contact
Credential Information
ex: CRS, CAAP, CCDP, etc.
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