Training Application Form

Criteria Used to Select Scholarship Recipients

✓ Employment in the substance abuse field	✓ Financial Need
✓ Potential impact of training for students contributions to the field	✓ Minority representation
✓ Consideration as to previous training and level of responsibility	✓ Recommendations

Module of Desired Enrollment:*

Module 1Module 2Module 3Module 4Module 5
Application Status:*

Non-MatriculatedMatriculated
What do you expect to gain from this training program (check all that apply):*

Orientation to Alcohol and Drug FieldIncreased KnowledgeCertificationRe-CertificationNew SkillsNetworkingOther (please specify)
Personal Information
Full Name*

First NameMiddle NameLast Name
Former Last Name
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Daytime Telephone
Evening Telephone
Cell Number*
Email *
Social Security Number*
Marital Status*
Birthdate*

MonthDayYear
Gender*

MaleFemaleOther
If you would like to be identified with a particular Ethnic Group, please complete:
Personal Information
Place of Employment
Telephone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Position Held
Length of Employment
Length in Field
Does your company provide tuition reimbursement?*

YesNo
If Yes, what percentage?
Does your company have a Direct Bill Contract with the Connecticut CADAC Training Program?

YesNo
If you thing your company may be interested in arranging a Direct Bill Contract, please provide us with the name of a Human Resource contact and their telephone number?
Human Resource Contact Name
Human Resource Contact Phone Number
Please enter a valid phone number.
Education Information

	Name and Address of School	Course of Study	Years Completed	Diploma or Degree Earned
High School (or Equivalency/GED)
Undergraduate College
Graduate Professional
Other (Specify)

	Name and Address of School (Type)	Course of Study (Registration #)	Years Completed (Expiration Date:)	Diploma or Degree Earned
Professional Licenses and Certifications

How did you learn about the Connecticut CADAC Training Program?

	Learned from	Where applicable, please identify the source in the space provided.
CADAC Training Alumni
CADAC Training Current Student
CADAC Training Faculty Member
CADAC Training Administrator
Newspaper
Radio Station
Employer
Web Page
Other

My signature below indicates that all information in my application is complete, factually correct, and honestly represented:

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Date

MonthDayYear
Date
Class Registration Form
Please complete the following information for each class you are registering for. If you are registering for a complete module, simply indicate only the Module Number and the start date (you do not have to list each class). Make additional copies of this form as needed.
Applicant Name

First NameLast Name
Social Security Number
Only numbers

Type a question

Connecticut Certified Alcohol and Drug Abuse