Request For Voluntary Relinquishment Of Certification - Boc
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110451 Mill Run Circle, Suite 200 • Owings Mills, MD 21117
877.776.2200 •
410.581.6222 •
410.581.6228 •
phone
local
fax
online www.
Request for Voluntary Relinquishment of Certification
If you have decided to relinquish your BOC certification(s), please use this form to notify BOC of your
decision.
Note that to be eligible for relinquishment, you must currently be certified in good standing. Suspended
or revoked certificants are not in good standing and therefore may not voluntarily relinquish their
credentials. Print, complete and sign this form and return to BOC to the attention of Credentialing
Manager, Michelle Yoon. Please mail your certificate to the address above or fax the form directly to
Ms. Yoon at 410.753.8809.
In accordance with Section I.3 of the BOC Recertification Policy, I am hereby requesting the
relinquishment of all certifications granted to me by the Board of Certification/Accreditation (BOC). By
signing this request below, I accept and agree to all terms and conditions applicable to voluntary
relinquishment, including those stated in Section I.3 of the Recertification Policy. Accordingly, I
understand and agree that (1) I may not make any representations or statements that I am an active BOC
certificant, certified by, or affiliated with, BOC; (2) I may not engage in any use of the BOC credential or
certification mark, until such time as I obtain reinstatement to active certification status; and, (3) I must,
upon submission of this request for relinquishment, return all original and copied BOC credential materials
to the BOC Office*. Further, I understand that this request for relinquishment is subject to the approval of
BOC, based on its determination of my eligibility for voluntary relinquishment under the applicable terms
of the Recertification Policy.
Name______________________________________ Certification Number________________
Signature ____________________________________ Date ____________________________
*Please submit with this form all original and copied BOC credential materials to BOC, including all
BOC certificates and pins. In the event that any such materials are unavailable or have been
destroyed, please provide a written statement attesting this to be the case.
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