RBT Competency Renewal Form
Use this form to submit and review your RBT competency renewal request. Please complete all sections to ensure a thorough evaluation.
Renewal Request ID
*
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Current Certification Status
*
Active
Expired (within 30 days)
Lapsed (over 30 days)
Date of Renewal Request
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Competency Areas for Renewal
*
Measurement
Assessment
Skill Acquisition
Behavior Reduction
Documentation & Reporting
Professional Conduct
Other
Supervisor/BCBA Name
*
Supervisor/BCBA Email
*
example@example.com
Supervisor Attestation: I confirm the applicant has demonstrated competency in the selected areas.
*
Yes, I attest
No, I do not attest
Submit
Should be Empty: