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Certification Application
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Portfolio # |
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BOARD USE ONLY |
Date ____/____/____
Application must be completed in its
entirety. Incomplete applications will not be considered, and returned to
applicant.
A separate application with supporting documentation is
required for each credential.
(Check only one):
□
CCFC- Clinically Certified Forensic
Counselor
□
CCJS - Certified Criminal Justice
Specialist
□
CDVC- Certified Domestic Violence
Counselor
□ CSOTS
- Certified Sex Offender Treatment Specialist
□
Addictions Specialty: Specify Specialty
_____________________________________________________________________
□ CCJTS
- Clinically Certified Juvenile Treatment Specialist
______________________________________________________________________________________
Last
Name First
Name Middle Initial
______________________________________________________________________________________
Address
City
State ZIP
______________________________________________________________________________________
Home
Phone Work
Phone Fax Number
E-Mail Address
Date of Birth
(mm/dd/yyyy):
_____/_____/________ Age: _____ SSN: _______-_______-__________
Supervisor:
______________________________________________________________________________________
Last
Name First
Name Title
______________________________________________________________________________________
Address
City
State ZIP
Phone
Number: ________-________-_______________ ext. _______________
BOARD
USE ONLY:
EDUCATION
Highest Grade Completed (circle one): 6 7 8 9 10 11 12 13 14 15
16 17 18 19
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Degree(s) |
Institution |
Major |
Year |
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MASTERS OF DOCTORAL PERTINENT COURSES
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Course |
Institution |
Credit Hours |
Brief
Description |
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BOARD USE ONLY:
PERTINENT EXPERIENCE
Please
include the last five years of paid or voluntary employment which are relevant
to this application, starting with your present position. In the section PROGRAM
TYPE, indicate In-Patient, Out-Patient, Screening, Detention, Corrections,
Probation/Parole, etc.
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Job title:
__________________________
__________________________
Program Name & Address:
__________________________
__________________________
__________________________
__________________________
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Program Type & Description:
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________ |
Working Hours/Week:
__________________________
Time Employed
(mm/yyyy):
From: ____/____
To: ____/____
Number of Years/Months:
_______YRS / _______MOS. |
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Job title:
__________________________
__________________________
Program Name & Address:
__________________________
__________________________
__________________________
__________________________
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Program Type & Description:
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________ |
Working Hours/Week:
__________________________
Time Employed
(mm/yyyy):
From: ____/____
To: ____/____
Number of Years/Months:
_______YRS / _______MOS. |
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Job title:
__________________________
__________________________
Program Name & Address:
__________________________
__________________________
__________________________
__________________________
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Program Type & Description:
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________ |
Working Hours/Week:
__________________________
Time Employed
(mm/yyyy):
From: ____/____
To: ____/____
Number of Years/Months:
_______YRS / _______MOS. |
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Job title:
__________________________
__________________________
Program Name & Address:
__________________________
__________________________
__________________________
__________________________
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Program Type & Description:
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________ |
Working Hours/Week:
__________________________
Time Employed
(mm/yyyy):
From: ____/____
To: ____/____
Number of Years/Months:
_______YRS / _______MOS. |
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Job title:
__________________________
__________________________
Program Name & Address:
__________________________
__________________________
__________________________
__________________________ |
Program Type & Description:
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________ |
Working Hours/Week:
__________________________
Time Employed
(mm/yyyy):
From: ____/____
To: ____/____
Number of Years/Months:
_______YRS / _______MOS. |
BOARD
USE ONLY:
Are
you licensed or certified by any state for a profession or skill?
□YES
□NO
If so,
what state? ____________ What profession or skill? _______________
Have you previously applied for certification?
□YES
□NO
If so,
when and under what name? _____________________________________________________________________
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