ADMINISTRATIVE APPEAL REQUEST FORM Email* Name* First Last Please describe yourself:*Please Select OneBCBABCBA-DBCaBARBTPursuing BCBAPursuing BCBA-DPursuing BCaBAPursuing RBTACE Provider CoordinatorVCS CoordinatorOtherMy appeal relates to:*Please Select OneSupervised ExperienceCourseworkDegreeRecertification/RenewalACE RenewalExamination ConditionsOtherPlease provide a brief explanation of the determination you are appealing:By clicking on the "I Accept" button below, you are agreeing to the following statement: I agree to hold the BACB harmless, and to waive, release and exonerate the BACB, its officers, directors, employees, committee members, panel members, and agents from any claims that I may have against the BACB arising out of the BACB's review of this appeal relating to eligibility for certification, renewal, recertification or reinstatement, issuance of a disciplinary (professional conduct) sanction or decision, and/or publication or third-party disclosure in accordance with BACB policies. Subject to your acceptance of these terms, the BACB agrees to review your appeal request.* I Accept Please upload any documents relevant to your appeal request. If you would like to submit multiple documents, they must be submitted as one single PDF. Drop files here or Accepted file types: pdf, gif, png, jpg, doc.