Recertification Application - Canadian Addiction Counsellors

PLEASE FILL OUT FORM COMPLETELY INCLUDING BOTH PAGES. INCOMPLETE FORMS WILL BE RETURNED
81 Bruce Street, Unit C
Kitchener, ON N2B 1Y7
Phone:
Toll Free:
Email:
519-772-0533
866-624-1911
519-772-0535
[email protected]
Web
www.caccf.ca
Fax:
Page 1 of 3
APPLICATION FOR RECERTIFICATION
Please fill in this form before printing your application (use the tab key to navigate through document). Enter in "none" "no" or "n/a" in
empty fields if not applicable. If filling in by hand PLEASE PRINT. Incomplete forms or forms with illegible hand writing will be returned
to you for completion and re-submission. The CACCF will not be responsible for late submissions if this form is not submitted correctly.
Check the box(s) that apply to your recertification
CADC D
ICADCD ICCDP D
Inactive Status D (specify)
ICCDPDD ICCAC D
ICCS D
ccs D
ICPS D
NOTE: late fees will apply to late submissions
Recertification Date (expiry date on your certificate)
NAME: Miss I Mrs. /Ms. /Mr./ Dr
HOME ADDRESS:
Street
Prov.
City
E-mail:
TELEPHONE:
Postal Code
BUSINESS NAME:
BUSINESS ADDRESS:
Street
City
TELEPHONE:
Prov.
E-mail:
Postal Code
** See table below for applicable taxes by province **
AMOUNT ENCLOSED:
PAYMENT METHOD:
D CHEQUE
D MONEY ORDER
Credit Card#
0
VISA
0
MASTERCARD
Expiry Date - - - - - -
Signature of Card holder _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
Please send your payment with your application directly to:
CANADIAN ADDICTION COUNSELLORS CERTIFICATION FEDERATION (CACCF)
81 Bruce Street, Unit C, Kitchener, Ontario N2B 1 Y7
Province
PE
ON. NL. NB
Fee
Tax
71.43 HST @ 14% 10.00
71.43 HST@ 13% 9.29
Total
$81.43
$80.72
Prov. Fee
Tax
NS
71.43 HST @15% 10.71
(others) 71.43 GST @05% 3.57
Total
$82.14
$75.00
CONTINUING EDUCATION
For for each course listed below a copy of the CACCF or IC&RC approval letter AND certificate(s) of attendance MUST be included.
Please be advised that 28 of the CEU hours must be core specific with the remaining 12 hours being related to addiction education. CEU's must
pertain to the knowledge and skills area, as per the Standards and Certification manual and be approved through the CACC F office.
APPROVED HOURS
COURSE TITLE
CORE RELATED
DATES
ATTENDED
LOCATION
SPONSORING INSTITUTION
OR ORGANIZATION
~~~~~~-DD~~~~~~-~~~~­
~~~~~~-DD~~~~~~-~~~~­
~~~~~~-DD~~~~~~-~~~~­
~~~~~~-DD~~~~~~-~~~~­
~~~~~~-DD~~~~~~-~~~~­
~~~~~~~DD~~~~~~-~~~~­
~~~~~~-DD~~~~~~-~~~~­
~~~~~~-DD~~~~~~-~~~~­
~~~~~~-DD~~~~~~-~~~~­
~~~~~~~DD~~~~~~-~~~~­
~~~~~~-DD~~~~~~-~~~~­
~~~~~~-DD~~~~~~-~~~~­
~~~~~~~DD~~~~~~-~~~~~~~~~~-DD~~~~~~-~~~~Total Core Hours
I have obtained a total of
DD
~I----~
Total Related Hours
CACCF or IC&RC approved Continuing Education hours within the past 24 months.
PRINT NAME:
SIGNATURE: ~~~~~~~~~~~~~~~~~~~
DATE:
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Page 3 of 3
81 Bruce Street Unit C
Kitchener, ON N2B 1Y7
Ph. 866-624-1911
Fax: 519-772-0535
Email: [email protected]
Web: www.caccf.ca
CANADIAN ADDICTION COUNSELLORS CERTIFICATION FEDERATION
SWORN AFFIDAVIT- PROOF OF WORK EXPERIENCE
NAME (full legal name):
Last
First
M.I.
MAILING ADDRESS (full legal address):
Street
City
Province
PHONE: Home: (
Postal Code
Work: (
Fax: (
My name is (full legal name): _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
I live in:
-----------------------------~
And I swear/affirm that the following is true:
I have been actively working in the substance abuse field for the past two years to date.
Swom~ffirmedbyme:
Dated on:
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
(Signature)
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