CAC II/AAC Application Form "*" indicates required fields 1Contact Information2Work Experience3Education / Related Data If you need assistance with this form, please contact us via email or call (1-877) 727-9217 Toll Free.Certification Manuals Click here to read the Certified Addiction Counsellor II (CAC II) manual and read about the certification requirements. Click here to read the Associate Addiction Counsellor (AAC) manual and read about the certification requirements.Certification Requirements* I have read the certification manual that I'm applying for and understand the requirements. Certification Applying For:* Certified Addiction Counsellor (CAC II) Associate Addictions Counsellor (AAC) Contact InformationPrefix*Mr.Mrs.Ms.First Name* First Last Name* Last Name as on Certificate (if different from above) Print name using English alphabet in order to appear on certificate. Do not include middle name.First and Last Name First Personal Phone*Business PhonePersonal Email* Business Email Home Address* Street Address City Province Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Business Address (if different from above) Street Address City Province Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Business Website Work Experience Current Position Present Position Title*From* MM slash DD slash YYYY To* MM slash DD slash YYYY Employer / Type of Business*# of Employees Supervised/Managed*Please upload a job description from HR or employer.File*Max. file size: 128 MB.Please upload a supervisor evaluation.File*Max. file size: 128 MB.Please upload two reference letters.Files* Drop files here or Select files Max. file size: 128 MB. Required Work Experience - CAC II (4000 Hours) To calculate number # hours per position: take # hours per week per position x # weeks per year x # years.Required Work Experience*DatesEmployerTitleJob Description Add RemoveNumber of Counselling Hours*Required Work ExperienceDatesEmployerTitleJob Description Add RemoveNumber of Counselling HoursRequired Work ExperienceDatesEmployerTitleJob Description Add RemoveNumber of Counselling HoursTotal Counselling Hours Formal Education State highest level obtained, year of graduation and any degrees/diplomas obtained.Formal Education*YearLevelInstitution Add RemovePlease upload your education certificates and transcripts.File* Drop files here or Select files Max. file size: 128 MB. If you are currently enrolled in further education, please complete the following:Name of College, University or InstitutionWebsite Address Faculty/DepartmentProgram NameSpecific Education List all professional degrees or education as required for certification: CAC II - 200 hours education in core competency areas / addictionsSpecified Education*Course/CredentialInstitutionNumber of Hours Add RemoveRelated Data Please provide information on any other experienced gained or position held which is relevant to your pursuit of becoming a certified addictions counsellor. Ex: teaching, leadership, innovation, consulting, volunteering, technical. RELATED DATA Add RemovePlease indicate where you received training/education related to the following:ScreeningIntakeOrientationAssessmentTreatment PlanningCounsellingCase ManagementCrisis InterventionClient EducationReferralRecords/Record KeepingConsultation with Other ProfessionalsCommentsAcknowlegement* Yes, I have read the CAC II/ AAC Manual Yes, I have read the Code of Ethics Yes, I have read and will adhere to the Professional Responsibilities and Code of Ethic. Yes, I understand this is a professional designation that must be maintained and renewed each year. By signing and submitting this application, it is assumed that you have read, understand, and agreed to the terms listed in this manual. Select AllConsent to ReleaseConsent to Release Information* I consent I do not consent with an explanation to CCPC Global Inc. consulting with any person who may have information on my competence and ethical standards of behaviour as listed on my application form.I do not consent with an explanation:* I consent I do not consent with an explanation CCPC Global Inc. inspecting any documents or records necessary, to determine my "acceptable standard" for certification. I hereby release from any liability, all representatives of CCPC Global Inc. and all individuals and organizations who provide information to CCPC Global Inc., while acting in good faith, to determine my credentials and character. I am aware that any false or misleading information deliberately given, will be considered a serious matter, and will be dealt with accordingly and may result in CCPC Global Inc requesting information from my present and past employers and any institution or agency with which I am, or have been, associated in a professional capacity. I understand that none of the information referred to herein constitutes "personal information" as defined under the Personal Information Protection and Electronic Documents Act.Signature*Date* MM slash DD slash YYYY You will be contacted about payment after the you submit the form.NameThis field is for validation purposes and should be left unchanged.
