Application for Certified Brain Injury Specialist Examination/Training

Application for Certified Brain Injury Specialist Examination/Training

Please type or print neatly. Mail completed application with resume and payment to: BIANYS, 10 Colvin, Albany, NY12206Or e-mail to , Or Fax to (518) 482-5285

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.

(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/GEDASSOCIATES BACHELOR’S

MASTER’SDOCTORATE

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 WITH RESUME & PAYMENT TO:
BIANYS, 10 Colvin, Albany, NY12206

Payment for one registration to CBIS class: $500 (check to BIANYS should be included with application)

Call Karen Thomas at (518)459-7911or e-mail ith any questions.