West Virginia Certification Board for Addiction and Prevention Professionals

West Virginia Certification Board for Addiction and Prevention Professionals
Application for Three-Year Approved Provider Status
Agency/Business Name:
Agency Contact Person

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
E-mail
example@example.com
Presiding Credentialed Entity Information
Name

First NameLast Name
Credentials Held (select all that apply):
Certification Number(s):
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
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Approved Provider Application Fee (Good for 3 Years) Do not select the boxes below unless paying with PayPal
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Approved Provider Application Fee (Good for 3 Years)
Checks and money orders in the amount of $300.00 can be made out to WVCBAPP and mailed to the board.

$300.00

Total

$0.00
Certificates of attendance must be provded to all participats free of charge.

I hereby attest that all information provided in this application is true and valid to the best of my knowledge.
Signature of the supervising credentialed entity:
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Presiding Credentialed Entity Information