Administrator Certification Bureau Forms

Forms are listed first by those used for administrator certification and then by those used by vendors.

Administrator Forms:

LIC 9214 – Application for Administrator Certification – Both initial and renewal applicants submit this form. In addition, this form is submitted by a previously certified administrator who did not renew their certificate within four (4) years from the date of expiration and so must reapply. NOTE: ACB is not responsible for reviewing the “high school diploma or equivalent …” so initial applicants DO NOT need to submit it with their LIC 9214.

LIC 9163 – Request for Live Scan Service –This form is used by the applicant to submit their fingerprints to the Department of Justice for processing. The applicant submits a copy to ACB with the initial administrator application.

Notice of Payment Information: Exam Fees – This form may be submitted by initial administrator certification applicants along with a check or money order for the exam processing fee.
 

Vendor Forms:

LIC 9141 – Vendor Application/Renewal – An individual, for profit or nonprofit business or governmental entity submits this form to request ACB approval to become a vendor and offer initial or continuing education courses for facility administrators.

LIC 9140 – Request for Course Approval – Vendors submit this request for ACB review and approval of a new or updated course.

LIC 9140A – Request to Add or Replace Instructor – Vendors use this form to request ACB approval to add or replace an instructor of an approved course.

LIC 9139 – Renewal of Continuing Education Course Approval – Vendors submit this form for ACB approval to renew previously approved courses and to continue to offer these unmodified courses.

LIC 9142A – Roster of Participants - for Vendor Use Only – Vendors use this form (or another format containing at least the same information) to report to ACB names of course participants.

Vendor Course Schedule Notification – Vendors submit this document with their quarterly course schedules to the ACB. Vendors may choose to use alternate course schedule documents that contain the same required information.

Notice of Payment Information: Vendor Fees – Vendors may submit this form along with a check or money order for the applicable vendor application processing fees.

Notice of Payment Information: Course Fees – Vendors may submit this form along with a check or money order for the applicable course processing fees.