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*

PrefixFirst NameMiddle NameLast NameSuffix

E-mail*

Confirmation Email

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number*

Area CodePhone Number

Choice of Examination Language*

EnglishSpanish

Month you wish to take examination in?*

Deadline is 2 months prior to testing week

For Which Examination Are You Applying?*

CADC ICADC IIMAC (CADC III)

Have you taken this examination before?*

NoYes

* Indicate Month/Year exam was taken*

* Indicate Name exam was taken under*

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

Level ILevel IIMACNone

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

YesNo

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

MonthDayYear

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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