West Virginia Certification Board for Addiction and Prevention Professionals

West Virginia Certification Board for Addiction and Prevention Professionals
436 12th Street, Suite C, Dunbar, WV 25064

304-768-2942
Individual Continuing Education Approval Form

This form is for certified individuals to utilize in getting approval for training that has not been approved through WVCBAPP by the sponsor of the training.
Date of Application

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

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Title of Training Event:
Sponsored By:
Location of the Training:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
EDUCATION TRAINING DESCRIPTION

Please read the "Knowledge and Skills", "Counselor Core Functions" or “Domains”.

Using the material designation indicate which will be emphasized in the training event. If you are applying for approval for an event which has several different sessions and presenters, please make multiple copies of the attached form.

Complete one form per session. The Continuing Education Committee requires that you submit this form with your re-certification application information, (certificate, etc.) documenting your attendance at each particular training.
How will you be paying the application fee?
Application Fee
prevnext( X )
Application Fee
Check or money orders are accepted via mail.

$10.00

Total

$0.00
Education Training Description
Title of Session
Date of Session

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Session Objectives
Knowledge & Skills Emphasized
Certification Core Functions Emphasized
Instructors Credentials
Other Information Useful in Evaluating Training
Number of Contact Hours
60 minutes =1 contact hour
Domains

Check all of the domains covered in the reported training
Counseling Domains:
Prevention Domains
Peer Recovery Support Specialist Domains
Upload Training Information

Cancelof
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:

West Virginia Certification Board for Addiction and Prevention Professionals

Application Fee

Education Training Description

Domains