BIP Certification Renewal Request CY 2024

Name

BIP Type

AssociateAutonomous

If Associate, provide the name of your BIP Supervisor:

Email Address of BIP Supervisor

example@example.com

Phone Number of BIP Supervisor

Please enter a valid phone number.

Certificate number

Place of Employment

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Business Phone

Cell Phone

Email address

example@example.com

Have you been convicted of a felony since your last application or renewal?

YesNo

If yes, list offense(s) and provide details below.

Have you been subjected to a disciplinary action by a professional credentialing board? If yes, provide details below.

YesNo

If yes, provide details below.

Have you been denied licensure or certification by a mental health credentialing board since your last application/renewal?

YesNo

If yes, provide details below.

Documentation of Continuing Education

1. # hours of training: blanks Date of training: Name/Title of training: blank Instructor:

2. # hours of training: blanks Date of training: Name/Title of training: blank Instructor:

3. # hours of training: blanks Date of training: Name/Title of training: blank Instructor:

4. # hours of training: blanks Date of training: Name/Title of training: blank Instructor:

5. # hours of training: blanks Date of training: Name/Title of training: blank Instructor:

6. # hours of training: blanks Date of training: Name/Title of training: blank Instructor:

7. # hours of training: blanks Date of training: Name/Title of training: blank Instructor:

8. # hours of training: blanks Date of training: Name/Title of training: blank Instructor:

9. # hours of training: blanks Date of training: Name/Title of training: blank Instructor:

10. # hours of training: blanks Date of training: Name/Title of training: blank Instructor:

Total number of training hours:

I request recertification as a Batterer Intervention Provider as defined in 920 KAR 2:210. I certify under penalty of law that the information contained herein is true, correct, and complete to the best of my knowledge and belief. I am aware that, should an investigation at any time disclose any such misrepresentation or falsification, my certification could be subject to disciplinary action.

I have completed at least 16 hours of continuing education in the past two(2) years related to domestic violence, pursuant to Section 2 of 920 KAR 2:210.

Signature

Date

Printed Name

BIP Renewal Request

Renewal Questions

AFFIDAVIT