Personal Credit for Providing Training Application

West Virginia Certification Board for
Addiction and Prevention Professionals
436 12th Street Suite C, Dunbar, WV 25064
Phone 304-768-2942
Email: wvcbapp@wvcbapp.org
Personal Credit for Providing Training Application

For use when documenting training presented as a WVCBAPP approved provider to count towards personal recertification.
Credit for Providing Continuing Education Units (CEUs):

Individuals who provide professional classes, trainings, workshops, seminars, webinars etc. will receive 0.5 hours of credit for every 1 hour of education provided, up to a maximum of 50% of the total CEUs required for recertification of the specific credential.

(Example: A six-hour workshop would count for three hours of credit.)

Note: Please upload a copy of the event description form with this application.
Before You Begin the Application

Ensure that all required documents are completed and available in one of the following formats: PDF, DOC, DOCX, XLS, XLSX, CSV, TXT, RTF, HTML, ZIP, MP3, WMA, MPG, FLV, AVI, JPG, JPEG, PNG, GIF.
Date*

MonthDayYear
Date
Name*

First NameLast Name
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
WVCBAPP Approved Provider Number*
Date of Training*

MonthDayYear
Date
Training Title*
Number of Contact Hours Provided to Participants *
Number of Hours Requested Towards Your Personal Recertification*
Certification Number(s)*
Certification Expiration Date*

MonthDayYear
Date
Approved Provider Expiration Date*

MonthDayYear
Date
WVCBAPP Certification(s) Held (select all that apply)*

AADCADCCCJPCSPRSS-MHPRSS-SUDPSIPS2
Upload a copy of the event description showing you as a presenter or trainer:*

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

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Date*

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