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Alcohol And Drug Counseling Certificate Program


You may click here to download a PDF version of the form or submit the below form online. If you do not have Adobe Reader to read the PDF file, you can download it from here.


*All registration has to be approved prior to admission.


I. Personal Information









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II. Employment Information

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III. Educational Information

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Yes No



IV. Emergency Information


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V. Please Tell Us

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VI. Acceptance & Agreement

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