MICHIGAN CERTIFICATION BOARD FOR ADDICTION PROFESSIONALS

Application form for

CASE PRESENTATION METHOD (CPM) ORAL EVALUATION

APPLICANT INFORMATION SECTION

Applicant’s Name

____________________________________________________________________________________

      First

 Middle Initial

 Last

Mailing Address

__________________________________________________________________________________________________

     Street    

 County

 State

 Zip Code

Daytime Telephone___________________________

TEST REGISTRATION INFORMATION

The CPM Oral Evaluation is tentatively scheduled for the second week in January, April, July, and October, depending on applicant interest. Once specific dates and times are set, applicants will be randomly assigned to a timeslot for their evaluation, which they will be notified of in writing.  In order to be scheduled the applicant must have submitted the registration form along with the $100.00 examination fee.

__________ I wish to be scheduled for the next available evaluation date ($100.00 fee enclosed)

Note: Your application and fee must be received in our office at least six weeks prior to test date.  Your fee pays for the timeslot you are scheduled for.  Once you are scheduled for an examination time, YOU CANNOT CANCEL OR RESCHEDULE WITHOUT FORFEITING YOUR EXAMINATION FEE.   In order to be reschedule for a future date you will be required to submit the registration application and $100.00 exam fee.

APPLICANT STATEMENT

I understand that I am registering for the Case Presentation Method (CPM) Oral Evaluation.  In order to register for this examination I must have taken and passed the IC&RC/AODA Counselor Exam.  I understand that in order to register for this exam I must submit this form along with the $100.00 exam fee.  Approximately four weeks prior to the evaluation date I will be randomly assigned an exam timeslot, which I will be notified of in writing.  I understand that I cannot cancel or reschedule my exam time without forfeiting my examination fee.

Signed________________________________________________________

Registration must be received at least six weeks before the exam date.  Make check or money order payable to MCBAP.  Mail completed application form and non-refundable examination fee to:

MCBAP

3474 Alaiedon Pkwy., Ste. 500

Okemos, MI 48864