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FORM

First Nations Wellness/Addictions Counsellor Certification Board

FIRST NATIONS WELLNESS/ADDICTIONS COUNSELLOR CERTIFICATION BOARD

APPLICATION FOR RECERTIFICATION
Renewal of certification every two years

APPLICANT’S FULL NAME ________________________________________________
First Middle Last
HOME ADDRESS _________________________________________________________
Street Town Province Postal Code
HOME PHONE (___) ____________ BUSINESS PHONE (___) ____________ EMAIL ____________
CURRENT CERTIFICATION LEVEL ___CERTIFICATE #______EXPIRATION DATE________________
Applying as Indigenous Certified Addictions Specialist I ___ II ____ III ____

NOTE: If you are applying for higher certification you must provide proof of any training, education, certificates, diplomas, degrees or otherwise that you have taken during the past two years. This must be sent, along with the fees, to the Registrar.

CURRENT EMPLOYER ______________________________________________________
BUSINESS ADDRESS ______________________________________________________
Street Town Province Postal Code
CURRENT POSITION _____________________________________________________
FIRST NATION AFFILIATION/ORGANIZATION _______________________________
OTHER AFFILIATION/ORGANIZATION ______________________________________

EDUCATION/TRAINING: Please list all training, education, courses that you have taken during the past two years. These 40 contact hours of training/education have been completed in the past 24-months since initial certification. These 40 hours must be specific to alcoholism and drug abuse counseling and/or related subjects. Please send copies of all certificates/transcripts verifying the 40 required hours.

1.         Education Institution_____________________________________
            Course _________________________________________________
            Date(s)__________________________________________________

2.         Education Institution_____________________________________
            Course _________________________________________________
            Date(s)__________________________________________________

3.         Education Institution_____________________________________
            Course _________________________________________________
            Date(s)__________________________________________________

4.         Education Institution_____________________________________
            Course _________________________________________________
            Date(s)__________________________________________________

5.         Education Institution_____________________________________
            Course _________________________________________________
            Date(s)__________________________________________________

6.         Education Institution_____________________________________
            Course _________________________________________________
            Date(s) _________________________________________________

PLEASE ENSURE THAT YOU HAVE ENCLOSED the $200 recertification fee with all the documents. Review of the recertification application will only proceed once all the documents and the fee have been received.

Registrar
First Nations Wellness/Addictions Counsellor Certification Board
104 – 1037 West Broadway, Vancouver, BC, V6H 1E3

Please visit our Publications section to download a copy of the Application Form.