West Virginia Certification Board for Addiction and Prevention Professionals

West Virginia Certification Board for Addiction and Prevention Professionals
Event Description Form

To be used to report training events to WVCBAPP after Approved Provider Status has been obtained.
Date of Training

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Approved Provider Agency/Business or Individual Name:
Title of Training Event:
Location of the Training:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Number of Contact Hours
60 minutes =1 contact hour
Domains

Check all of the domains covered in the reported training
Counseling Domains:

Other
Prevention Domains

Other
Peer Recovery Support Specialist Domains

Other
Upload Training

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Upload Sample Certificate for this event

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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 year
Should be Empty:

Domains