Licensed Consultant Reinstatement Request Page 1 Thank you for your interest in reinstating your Licensed Consultant status. Please complete the form below. Someone from the Standards for Excellence Institute will respond to your inquiry within the week. OK Question Title * First Name OK Question Title * Last Name OK Question Title * Year of Licensed Consultant Training OK Question Title * I am interested in re-instating my Standards for Excellence Licensed Consultant status. Yes No OK Question Title * Phone OK Question Title * Email OK Question Title * Mailing Address Line 1 OK Question Title * Mailing Address Line 2 OK Question Title * City OK Question Title * State OK Question Title * Zip Code OK Please submit one of the following OK Question Title * LinkedIn Profile OK Question Title * Resume OK Question Title * I understand that reinstatement into the Licensed Consultant program is not guaranteed. I understand reinstatement is contingent upon: Re-acceptance into the Standards for Excellence Licensed Consultant program (which includes consultation with local Standards for Excellence replication partner where applicable) My participation in a Standards for Excellence Pass to Excellence,Clinic Series or other similar series/course offered by the Standards for Excellence Institute or a licensed replication partner at my own expense, including fees, travel, etc. Payment of $150 reinstatement fee, plus optional purchase of Standards for Excellence codebooks and other materials.Entering into a new Standards for Excellence Licensed Consultant agreement (including payment of applicable annual licensing fees moving forward) Yes No OK DONE