Please mark the item you are requesting. Please note that some items require fees to be sent with them in order to receive them. Please include the appropriate fee when ordering items from this form. Fees are accepted in the form of a check or money order made payable to : MCBAP. Please mail the completed form (and fees if applicable) to the following address: |
| Michigan Certification Board for Addiction Professionals |
3474 Alaiedon Parkway Suite 500 |
| Okemos, MI, USA, 48864
|
| 1. | IC&RC Exam Registration Application _____ (please specify quantity), this form needs to be completed in order to get registered for the IC & RC AODA Counselor, IC & RC Prevention Specialist, IC & RC DOT/SAP, IC & RC CCJP, and IC & RC Clinical Supervision Written Examinations. There are fees required for these exams. There is no charge for this form. (Click here for Print Version of this application) . |
| 2. | Case Presentation Method (CPM) Oral Exam Registration Application (Click here for Print Version of this application) |
| 3. | Certification Application Manuals: There is a $25.00 charge per manual. Be sure to include check or money order payable to MCBAP along with this order form. Please specify the quantity for each manual: |
| ___ | Certified Addictions Counselor (CAC) Manuals; |
| ___ | Certified Advanced Addictions Counselor (CAAC) Manual; |
| ___ | Certified Prevention Specialist/ Consultant (CPS and CPC) Manual (s); |
| ____ | Certified Clinical Supervision (CCS) Manual (s); |
| ____ | Certified Criminal Justice Professional (CCJP) Manual (s); |
Shipping Information: |
| Name: | ____________________________________________________________ |
| Company Name: | ____________________________________________________________ |
| Address: | ____________________________________________________________ |
| ____________________________________________________________ | |
| ____________________________________________________________ | |
| Phone (Include Area Code): | ____________________________________________________________ |
| Fax/ Email | ____________________________________________________________ |
| Other Information: | ____________________________________________________________ |
Rev. 01/2008