MICHIGAN CERTIFICATION BOARD FOR ADDICTION PROFESSIONALS
IC&RC INTERNATIONAL CERTIFICATION WRITTEN EXAMINATION
APPLICATION FORM

APPLICANT INFORMATION:

Applicant’s Name____________________________________________________________________

First

Middle Initial

Last

Mailing Address _____________________________________________________________________

                         ____________________________________________________________________________________

City

State

Zip Code

Daytime Telephone (_____)____________________

TEST REGISTRATION INFORMATION:

 

I wish to register for the following IC&RC International Certification Written Examination:   

 I have enclosed the fee of:              

Certification                      

 

 Alcohol and Other Drug Abuse (AODA) Exam    

 ________   

 $ 100.00   

 ______   

 (CAC)

 Clinical Supervisor (CCS) Exam   

 ________   

 $ 100.00   

 ______   

 (CCS)

 Prevention Specialist/Consultant (CPS/CPC) Exam 

 ________   

 $ 100.00   

 ______   

 (CPS/CPC)

Certified Criminal Justice Professional (CCJP) Exam    

 ________   

 $ 100.00   

 ______   

 (CCJP)

DOT Exam (required for Substance Abuse Profs)   

 ________   

 $ 125.00   

    

 

 

 

__________ Check here if you are taking this exam to reapply for certification.

 

Exams are offered on the second Friday of March, June, September and December.  Exam locations are: Lansing, Detroit, Marquette and Gaylord areas at 10:00 a.m.  If there is not enough applicant interest in any one location, that location will be cancelled.  

 

 

Please schedule my exam for the following date and location:

MARCH   

 JUNE   

 SEPTEMBER   

 DECEMBER

_____ Lansing   

 _____ Lansing   

 _____ Lansing   

 _____ Lansing

____Detroit   

 _____Detroit   

 _____Detroit   

 _____Detroit

______Marquette   

 ______ Marquette   

 _______ Marquette   

 _______ Marquette

____Gaylord   

 _____Gaylord   

 _____Gaylord   

 _____Gaylord

 

Note: Your registration form and non-refundable exam fee must be received in our office at least six weeks prior to test date.  THERE ARE NO CANCELLATIONS OR POSTPONEMENTS, upon submission of your registration form and non-refundable exam fee, you have confirmed your seat and exam booklet for the scheduled text date.

 



I understand that: 

1. The exam fee is non-refundable.
2. THERE ARE NO CANCELLATIONS OR POSTPONEMENTS.

3. I will receive a confirmation letter at two weeks prior to the testing date; and

4. I must have a photo ID to gain admittance.

 

 

 

Signed_________________________________________________________

 

Return the completed application form and non-refundable exam fee to MCBAP, 3474 Alaiedon Parkway, Suite 500 Okemos, MI 48864 at least six weeks prior to the exam date.  Make check or money order payable to MCBAP.  For more information regarding the IC&RC examinations, or if you do not receive a confirmation letter at least two weeks prior to the exam date, contact MCBAP at (517) 347-0891.

DISABILITY/RELIGIOUS RELATED NEEDS

Individuals with disabilities and/or religious obligations that require modifications in test administration, may request specific procedure changes, in writing six weeks prior to the scheduled test date.  With the written request, the candidate must provide official documentation of the disability or religious issue.


EXAM AND STUDY GUIDE INFORMATION

 

Alcohol and Other Drug Abuse (AODA) Study Guide-The five major performance domains addressed in the IC&RC Counselor exam are Assessment, Counseling, Case Management, Education, and Professional Responsibility.  The AODA study guide may be purchased from the Michigan Resource Center, 111 West Edgewood Blvd., Suite 11, Lansing, MI 48911 (1-800-626-4636).

 

Prevention Specialist/Consultant (CPS/CPC) Study Guide-The six major performance domains addressed in the IC&RC Alcohol, Tobacco, and Other Drug Abuse Prevention Specialist exam are Program Coordination, Education and Training, Community Organization, Public Policy, Professional Growth and Responsibility, and Planning and Evaluation.  The Prevention study guide may be purchased from the Michigan Resource Center, 111 West Edgewood Blvd., Suite 11, Lansing, MI 48911 (1-800-626-4636).

 

Clinical Supervisors Exam (CCS)  Study Guide-The four major performance domains addressed in the IC&RC Clinical Supervisor exam are Assessment and Evaluation, Counselor Development, Professional Responsibility, and Management and Administration.  The Clinical Supervisors exam study guide may be purchased from IC&RC/AODA, Inc., 1602 I (Eye) Street, NW, Suite 210, Washington, DC 20006 (1-202-785-0683).


 

DEMOGRAPHIC INFORMATION

 

Completion of this section is optional.  Information contained in this section is not used for registration purpose, but is used for statistical reporting.  At your option, indicate your educational level, racial/ethic group, and gender.

 

Indicate your highest educational level below:   

 Indicate your racial/ethnic group below:

(Check only one)   

 (Check only one)

_____ No High School Diploma   

 _____ Caucasian

_____ High School Diploma or GED   

 _____ Black/African-American

_____ Vocational Certification   

 _____ American Indian/ Alaskan Native

_____ Associate of Arts/Associate of Science Degree   

 _____ Asian or Pacific Islander

_____ Bachelor’s Degree   

 _____ Hispanic

_____ Master’s Degree   

 _____ Other

_____ Doctoral   

 

Indicate your gender below: (check only one)   

 Years of experience: __________

_____ Male   

_____ Female   

 

For office use only:

Registration #______________________   

 Amount Paid _________________   

 Check # _____________   

Date Paid__________   

   

  

MCBAP

3474 Alaiedon Parkway, Suite 500

Okemos, MI 48864

Revised 01/2008