West Virginia Certification Board for Addiction and Prevention Professionals

West Virginia Certification Board for Addiction and Prevention Professionals
Application for Three-Year Approved Provider Status
Date*

MonthDayYear
Date
Agency/Business Name:*
Agency Contact Person*

First NameLast Name
Address*

Street Address

Street Address Line 2

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Phone Number*
E-mail*
example@example.com
Presiding Credentialed Entity Information
Name*

First NameLast Name
Credentials Held (select all that apply):*

PRSS-MHPRSS-SUDADCAADCCSPSIPSIICCJPCSPRSSCSPRSS-CL
Certification Number(s):*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Upload Your Training Materials *

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Approved Provider Application Fee (Good for 3 Years)
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Approved Provider Application Fee (Good for 3 Years)There is an 8% charge for PayPal usage. Checks and money orders in the amount of $300.00 can be made out to WVCBAPP and mailed to the board.
$324.00

Total

$0.00
Certificates of attendance must be provded to all participats free of charge.

I hereby attest that all information provided in this application is true and valid to the best of my knowledge.
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Presiding Credentialed Entity Information