Michigan Certification Board for Addiction Professionals
3474 Alaiedon Parkway, Suite 500, Okemos MI 48864

Application For Renewal

PDF Form

Please complete this document and do not submit any additional documentation at this time
If you have not renewed your credential prior to its expiration date you are allowed 90 days after your expiration date to successfully meet all renewal requirements and submit all necessary fees including late fees. If you fail to renew your credential within the 90 days allowed and you wish to hold this credential, you must reapply meeting all current standards, which may include additional documentation and/or exams. You must meet all continuing education requirements in order to be eligible for renewal.

SECTION I: Renewal Information: The following information must be completed

ARMS-I _____	ARMS-II _____	CAC-M _____	CAAC_____
CCS _____	CPS _____	CPC _____	CCJP _____
CAC-R _____

SECTION II: Demographics (Please Print)

Name___________________________________	Social Security No. ________________ (last 4 digits only)
Address_________________________________	County _______________________
City __________________________	State __________ Zip Code ______________
Home Phone (_____)_________________	Daytime Phone (_____)_________________
Email Address_________________________________

SECTION III: Renewal Fees

Remit a non-refundable renewal fee of $125.00 for a 2 (two) year certification period OR $75.00 for a 1(one) year certification period and an additional $25.00 late fee if applying after expiration date. NOTE: Individuals who hold CCS credentials must pay an additional $25.00 renewal fee.

_____ Check here if applying for the Older Adult Status and provide all necessary documentation.

Certified Professionals who are retired from full-time employment may request an “older adult” status. To be eligible, the individual must document that they are at least 62 years of age, and that they are no longer employed full-time. Renewal continuing education standards will remain the same, however the fee will be waived.

By submitting this application, I attest that I have earned the required number of continuing education hours for the *preceding certification period. I understand it is my responsibility to maintain evidence of my compliance with the continuing education requirement for a period of 2 (two) years from the date of submission of this application and that I am subject to an audit of such evidence. I also attest that there has not been any complaints filed against me that would be viewed as unethical during my proceeding certification period.
*NOTE: Twenty (20) hours of continuing education is required for each year of the preceding certification period.

SECTION IV: Signature statement

In signing, I acknowledge that the MCBAP Board considers this document as my application for renewal of my credential. I agree and hereby certify that all the above information is understood, true and accurate. I also agree to adhere to the current code of ethics.

Signature ___________________________________

Date ___________________

SECTION V: Data Collection

Please fill out the Data Collection section. This data is important in identifying the on-going status of substance abuse workforce in the state of Michigan. The information will assist with identification of future needs, e.g. competency standard, credentialing, training, education, future funding and other planning activities. The aggregate data will be shared with groups such as providers, Regional Coordinating Agencies, Office of Drug Control Policy, elected officials and other interested parties.

Type of service in which you spend the majority of your time

_____ Prevention	_____Detoxification
_____Residential	_____Intensive Outpatient
_____Outpatient	_____Methadone
_____Supervision/Management/Administration

Typical hours worked per week in substance abuse treatment or prevention work __________Hours

Primary role/responsibility function

_____Primary Therapist	_____Didactics
_____Case Management	_____AAR Screener/Assessor
_____Clinical Supervisor	_____Medical/Psychiatric
_____Administrator	_____Residential Aid/Milieu Technician
_____Other _______________

Annual salary from treatment or prevention work (optional)

_____$ 0 - $10,000	_____$31,000 - $40,000	_____$61,000 - $70,000
_____$11,000 - $20,000	_____$41,000 - $50,000	_____$71,000 - $80,000
_____$21,000 - $30,000	_____$51,000 - $60,000	_____$81,000 - $90,000 plus

Gender (optional)_____ Female _____Male

Primary Race/Ethnic Group (optional)

_____White/Caucasian (non-Hispanic)	_____Asian American
_____Black/African American (non-Hispanic)	_____Native American/Indian
_____Native Hawaiian/Pacific Islander	_____Alaska Native
_____Hispanic/Latino	_____Arab/Chaldean
_____Other (please specify) _______________

Certification(s)/Licensure(s) (identify ALL and if temporary status)

CONTINUING EDUCATION FORM

(Please type or print legibly)

List each training course, seminar, workshop, etc., date(s), contact hours, substance abuse specific or related using this format.
DO NOT ATTACH DOCUMENTATION (Make copies of this form if additional space is required.)

__________________________________________________________________________

Applicant Name Soc. Sec. No. (last 4 digits only)

_____________________________________________________________________________