THE AMERICAN BOARD OF PATHOLOGY
REPLACEMENT CERTIFICATE REQUEST FORM

The ABPath does not issue duplicate certificates. To request a replacement certificate to be engraved, complete and submit this form to the ABPath along with credit card authorization or check for $100.00. The replacement certificate will indicate that the certificate is a replacement and the date of the replacement. Do not check more than one certificate below. If more than one certificate needs to be replaced, a Replacement Certificate Request Form must be completed and submitted with payment for each certificate.

INSTRUCTIONS:
Please submit the full name and Last 4 digits of social security number or the Date Of Birth for each certificate request.
Due to the extensive engraving process, it may take up to 30 days to receive your certificate.
Once this form is completed, please click the "Continue to the Payment page" button at the bottom to enter your payment on the next page.

Replacement Certificate type

The primary certificate I wish to replace is:

Combined Anatomic Pathology and Clinical Pathology (APCP)

Anatomic Pathology only (AP)

Clinical Pathology only (CP)

AP/Cytopathology

AP/Forensic Pathology

AP/Hematology

AP/Medical Microbiology

AP/Neuropathology

CP/Blood Banking/Transfusion Medicine

CP/Chemical Pathology

CP/Hematology

CP/Medical Microbiology

Voluntary Recertification

The subspecialty certificate I wish to replace is:

Blood Banking/Transfusion Medicine

Chemical Pathology

Cytopathology

Clinical Informatics

Dermatopathology

Forensic Pathology

Hematopathology

Medical Microbiology

Molecular Genetic Pathology

Neuropathology

Pediatric Pathology

Reason for requesting a Replacement Certificate

Name and Title Preference

Title Preference:

It is the policy of The American Board of Pathology to use only the titles "M.D.," meaning Medical Doctor, or "D.O.," Doctor of Osteopathy, after the diplomate’s name on the certificate. A diplomate may elect to have no title after his/her name. Examples: Herbert Henry, M.D.; Herbert Henry, D.O.; Herbert Henry

Name to be inscribed on Replacement Certificate:

Information on physician requesting the Replacement Certificate

Send Replacement Certificate to:

Name:

Address:

Total:

$

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