Personal Credit for Providing Training Application

West Virginia Certification Board for
Addiction and Prevention Professionals
436 12th Street Suite C, Dunbar, WV 25064
Phone 304-768-2942
Email: wvcbapp@wvcbapp.org
Personal Credit for Providing Training Application

For use when documenting training presented as a WVCBAPP approved provider to count towards personal recertification.
Credit for Providing Continuing Education Units (CEUs):

Individuals who provide professional classes, trainings, workshops, seminars, webinars etc. will receive 0.5 hours of credit for every 1 hour of education provided, up to a maximum of 50% of the total CEUs required for recertification of the specific credential.

(Example: A six-hour workshop would count for three hours of credit.)

Note: Please upload a copy of the event description form with this application.
Before You Begin the Application

Ensure that all required documents are completed and available in one of the following formats: PDF, DOC, DOCX, XLS, XLSX, CSV, TXT, RTF, HTML, ZIP, MP3, WMA, MPG, FLV, AVI, JPG, JPEG, PNG, GIF.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Name

First NameLast Name
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
WVCBAPP Approved Provider Number
Enter 0 for auto approved entities
Date of Training

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Training Title
Number of Contact Hours Provided to Participants
Number of Hours Requested Towards Your Personal Recertification
Certification Number(s)
Certification Expiration Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Approved Provider Expiration Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate. If auto approved, choose today's date
WVCBAPP Certification(s) Held (select all that apply)
Upload a copy of the event description showing you as a presenter or trainer:

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

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