Re-Test Application

This form is meant for people who took the NAADAC Level 1, NAADAC Level 2, or MAC exam and did not pass

If you have taken either of the exams within the last year, this is the ONLY form you need to submit to take the test again.

Full Name *

Prefix First Name Middle Name Last Name Suffix

E-mail *

Confirmation Email

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Phone Number *

Area Code Phone Number

Choice of Examination Language *

English Spanish

Month you wish to take examination in? *

Deadline is 2 months prior to testing week

For Which Examination Are You Applying? *

CADC I CADC II MAC (CADC III)

Have you taken this examination before? *

No Yes

* Indicate Month/Year exam was taken *

* Indicate Name exam was taken under *

Are you currently certified in addiction counseling by NCC AP? *

Level I Level II MAC None

Are you a member of NAADAC? (Membership is not required) *

Yes No

Release Authorization must be completed by all candidates authorizing release of test results to a state/commonwealth.

I hearby authorize the National Certification Commission for Addiction Professionals (NCC AP) to release the results of my Certification Examination for Addiction Counselors to the Addiction Counselor Certification Board of Oregon. I understand that these test resultsw ill be used only for state/commonwealth certification at this time.

I have read the Candidate Information Leaflet and understand I am responsible for knowing its contents. I certify that the information given inthis Application is in accordance with the leaflet and is accurate, correct and complete.

*

Candidate Signature

*

Month Day Year

*

Re-Test Fee $ 180.00

Total $ 0.00

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

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