MICHIGAN CERTIFICATION BOARD by kaq14266

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

APPLICANT INFORMATION:
Please type or print clearly

Applicant’s
Name____________________________________________________________________________
                           First              Middle Initial                         Last
Mailing Address
_____________________________________________________________________________

_________________________________________________________________________________________
__
              City                State                       Zip Code

Daytime Telephone (_____)_________________________

*REQUIRED Email Address:_____________________________________________


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

                                                                         I have enclosed the fee of:
Alcohol and Other Drug Abuse (AODA) Exam for CAC-R                       ________            $140.00
Advanced Alcohol and Other Drug Abuse (AAODA) Exam for CAAC              ________            $140.00
Clinical Supervisor (CCS) Exam                                           ________            $140.00
Prevention Specialist/Consultant (CPS/CPC) Exam                           ________           $140.00
Certified Criminal Justice Professional (CCJP) Exam                      ________            $140.00
Certified Co-Occurring Disorder Professional (CCDP) Exam                 ________            $140.00
DOT Exam (required for Substance Abuse Profs)                            ________            $165.00
                                                                         .
Please schedule my exam for the following date and location (Select 1 st and 2 nd choices for exam location)
If there are not enough registrants for one particular exam location, that location will be cancelled by the MCBAP
office.

MARCH 12, 2010 JUNE 11, 2010          SEPTEMBER 10, 2010                             DECEMBER 11, 2009
___ Lansing            ___Lansing           ___Lansing                                     ___Lansing
___Troy                       ___Troy                                      ___Troy
        ___Troy
___Gaylord             ___Gaylord           ___Gaylord                                        ___Gaylord
___Marquette           ___Marquette         ___Marquette                                      ___Marquette

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 test 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 least two weeks prior to the testing date; and
                           4. I must have a photo ID to gain admittance.

Signed________________________________________________________ _

Return the completed registration form and non-refundable exam fee to the address below 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.
                                                         MCBAP
                                           3474 Alaiedon Parkway, Suite 500
Okemos, MI 48864
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 Distance Learning Center or IC&RC website.

Advanced Alcohol and Other Drug Abuse (AAODA) Study Guide- The five major performance domains addressed in
the IC&RC Advanced Counselor exam are Assessment, Counseling, Case Management, Education, and Professional
Responsibility. The AAODA study guide may be purchased from the Distance Learning Center or IC&RC website.

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 Respons ibility, and Planning and
Evaluation. The Prevention study guide may be purchased from the Distance Learning Center or IC&RC website.

Clinical Supervisor (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 Supervisor exam study guide may be purchased from IC&RC/AODA,
Inc., 298 South Progress Ave., Harrisburg PA 17109 (717) 540-4457.

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 grou p, 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 August 28/2009

								
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