CEB — Two Year Renewal

Application for Recertification

Two (2) Years — AADC / CCDP / CCDP-D / CCJP
Dear AADC, CCDP-D, CCDP, and/or CCJP holders, please refer to the LASACT website for additional information on two-year period recertification. If you plan to let your credential lapse, please alert the LASACT office so that our files and database can be adjusted.

AADC recertification applications are exempt from submitting continuing education as the proof of practice credential renewal verifies hours are current.
SECTION 1: Applicant Information
Name to appear on certificate(s):
Email Address (Required)
example@example.com
Confirm Email Address (Required)
example@example.com
Primary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Phone Number (if applicable)
Please enter a valid phone number.Format: (000) 000-0000.
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Place of Employment
Employer's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Required Enclosures: Please check each item to verify that a copy is attached

Copy of current Right to Practice Credentialing Card or other masters level credentialing card showing an approximate expiration date of six weeks prior to your AADC, CCDP, CCDP-D, or CCJP renewal date. Your AADC, CCDP, CCDP-D, or CCJP renewal cannot be processed until we receive a copy of your card verifying that you hold a current and valid right to practice credential.
Cancelof

Recertification Payment Options

Convenience fees will be assessed on all credit/debit card payments.
Credentials applying to be recertified:
Select all that apply to your renewal:
prevnext( X )
One Credential Current LASACT Member Rate
Recertification fees are $120 for LASACT members. Price includes: $120 recertification fee + $4.68 transaction fee for all credit/debit card payments.

$124.68 Quantity



One Credential Non-LASACT Member Rate
Recertification fees are $180 for non-LASACT members. Price includes: $180 recertification fee + $7.02 transaction fee for all credit/debit card payments.

$187.02 Quantity
Item subtotal:$0.00



More Than One Credential Current LASACT Member Rate
Recertification fees are $150 for LASACT members. Price includes: $150 recertification fee + $5.85 transaction fee for all credit/debit card payments.

$155.85 Quantity



More Than One Credential Non-LASACT Member Rate
Recertification fees are $305 for non-LASACT members. Price includes: $305 recertification fee + $11.90 transaction fee for all credit/debit card payments.

$316.90 Quantity
Item subtotal:$0.00



Late Fee
Late fee for each certificate renewal submitted after the expiration date. Price includes: $50 late fee + $1.95 transaction fee for all credit/debit card payments.

$51.95 Quantity



International Certificate
Charge for each Official International. Price includes: $25 international certificate.

$25.00 Quantity



Total

$0.00
Summary of Continuing Education

Continuing Education Requirement: A total of 40 hours in integrated services, co-occurring disorders, and/or dual diagnosis is required.
Instructions:
- Enter only one educational event per row;
- Provide the information requested in each column for each educational event;
- Number of hours must total a minimum of 40 for the certification period;
- Attach a copy of a certificate for each educational event listed. Certificates must show the provider, date(s), title of event, speaker/presenter, number of contact hours completed, and your name. Certificates without this information will be rejected;
- If college or university credit was given, hours are detemined at the rate of 15 clock hours per semester credit hour;
- Hours recieved up to 90 days preceding this cycle can used if they were not used in a previous renewal cylce;
- AADC recertification applications are exempt from submitting continuing education as the proof of practice credential renewal verifies hours are current.

Rows	Date	Provider	Title	Number of Hours
Item 1
Item 2
Item 3
Item 4
Item 5
Item 6
Item 7
Item 8
Item 9
Item 10
Item 11
Item 12
Item 13
Item 14
Item 15
Item 16
Item 17
Item 18
Item 19
Item 20
Item 21
Item 22
Item 23
Item 24
Item 25
Item 26
Item 27
Item 28
Item 29
Item 30
Item 31
Item 32
Item 33
Item 34
Item 35
Item 36
Item 37
Item 38
Item 39
Item 40

Certificate Upload

Cancelof
Signature belows denotes that the applicant:

1. Is currently active in the field of alcohol and substance abuse;

2. Is free of any ethical or malpractice violation;

3. Accepts all of the principles of the Code of Ethics and Disciplinary procedure;

4. Applicant understands that the AADC/CCPD-D certificate is not a substitute or a replacement for the Social Worker credential and therfore is NOT a license with which to practice substance abuse counseling.
Signature
Should be Empty:

Application for Recertification

SECTION 1: Applicant Information

Recertification Payment Options

Select all that apply to your renewal:

Summary of Continuing Education