GMHCN Request for Training Verification
Requester's Information:
Full Name
*
First Name
Last Name
Agency Name
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
E-mail
*
example@example.com
Please select who you are requesting information for
*
Please Select
I am requesting materials for myself
I am requesting materials for an employee/potential employee
Training Cohort Number
Please Select
1
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100
Are you requesting information for more than one person?
*
Please Select
Yes
No
Certified Peer Specialist-MH Information:
Full Name
*
First Name
Middle Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
E-mail
*
example@example.com
Please upload the consent form to release training materials
*
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of
Certified Peer Specialist-MH 2
Full Name
First Name
Middle Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
E-mail
example@example.com
Please upload the consent form to release training materials
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of
Certified Peer Specialist-MH 3
Full Name
First Name
Middle Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
E-mail
example@example.com
Please upload the consent form to release training materials
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Cancel
of
Certified Peer Specialist-MH 4
Full Name
First Name
Middle Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
E-mail
example@example.com
Please upload the consent form to release training materials
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Cancel
of
Certified Peer Specialist-MH 5
Full Name
First Name
Middle Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
E-mail
example@example.com
Please upload the consent form to release training materials
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Cancel
of
Certified Peer Specialist-MH 6
Full Name
First Name
Middle Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
E-mail
example@example.com
Please upload the consent form to release training materials
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Cancel
of
Certified Peer Specialist-MH 7
Full Name
First Name
Middle Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
E-mail
example@example.com
Please upload the consent form to release training materials
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of
Certified Peer Specialist-MH 8
Full Name
First Name
Middle Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
E-mail
example@example.com
Please upload the consent form to release training materials
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Cancel
of
Certified Peer Specialist-MH 9
Full Name
First Name
Middle Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
E-mail
example@example.com
Please upload the consent form to release training materials
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Certified Peer Specialist-MH 10
Full Name
First Name
Middle Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
E-mail
example@example.com
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Order Information
Delivery Recipient Contact Information
*
Send materials to requesters email/address listed above
Send materials to different email/address
Full Name
*
First Name
Last Name
E-mail
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
My Products
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( X )
CEU Verification
Includes verification letter and list of all CEUs that have been submitted for the current year
$
30.00
Quantity
Price
Electronic Copy
1
2
3
4
5
6
7
8
9
10
$
30.00
Hard Copy
1
2
3
4
5
6
7
8
9
10
$
35.00
CPS Certification Verification
Includes a copy of active cps certification and letter
$
25.00
Quantity
Price
Electronic Copy
1
2
3
4
5
6
7
8
9
10
$
25.00
Hard Copy
1
2
3
4
5
6
7
8
9
10
$
30.00
CPS Replacement Certificate
Includes hard copy replacement of current CPS certification. Mailing fee has been calculated into the price.
$
40.00
Quantity
1
2
3
4
5
6
7
8
9
10
Expedited Processing Fee
Materials will be process in 3-5 business days
$
15.00
Mailing Fee
Select this option if requesting hard copies
$
10.00
Duplicate Copies of Training Certificates
Please list the name of training certificates in the box below
$
5.00
Quantity
1
2
3
4
5
6
7
8
9
10
Please list name of training certificate you would like to receive a duplicate copy. Please note: that the number of trainings listed should match the quantity selected in the Duplicate Copies of Training Certificate above.
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