Replacement/Duplicate Certificate Request Form

Replacement/Duplicate Certificate Request
Diplomate Information

**Important** Your certificate will be issued with your full name and degree as recorded with the ABR. Please check the ABR's Public Reporting Page to verify this is how you would like your new certificate to appear.

If this is not correct, please email adminsupport@theabr.org, with your updated information, including supporting documentation (drivers license, passport, marriage/divorce certificate, diploma, etc.) prior to submitting this request.
First Name *
Middle Name
Last Name *
Date of Birth *

Month Day Year
Date
ABR ID (if known)
E-mail Address *
Phone Number *

Area Code Phone Number
Address to where certificate should be sent
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Certificate Information
Please check all that apply to the certificate you are requesting *

Diagnostic Radiology Radiation Oncology Medical Physics Interventional Radiology/Diagnostic Radiology Nuclear Radiology Neuroradiology Pediatric Radiology
Submission Process
- Once your form has been received by the ABR, the fee ($100.00) will be charged to your myABR account within 3-5 business days. You will be notified when this is available to pay.
- Upon payment, your certificate will be ordered and we will let you know when you should receive it.
For questions or concerns please contact: adminsupport@theabr.org or call
(520) 790-2900
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