Express Paperless Initial Individual Registration – Addiction Counselor Certification Board of California

Initials(Required)

Last Name(Required)

First Name(Required)

Middle Name

Address(Required)

Street Address City State ZIP Code

Phone Number(Required)

Email Address(Required)

Enter Email Confirm Email

Date of Birth MM/DD/YYYY(Required)

Last 4 SSN(Required)

Have you ever applied to the ACCBC under another name(Required)

Yes

Previous Name Used(Required)

Have you ever held registration or certification with any AOD certifying organization(Required)

Yes

If yes name of certifying organization(Required)

Have you ever had your AOD registration or certification suspended or revoked(Required)

Yes

Name of suspended certifying organization(Required)

Please Explain(Required)

Signature of Applicant(Required)

For Registration renewal policies and procedures, please refer to Section 1 of the CATC Handbook, which can be found on the ACCBC website at https://www.accbc.org/stats-info/form-library/. I have read and understand the processes as outlined in the CATC Handbook describing policies and procedures and other pertinent information about Certification. I have read and agree to abide by the ACCBC Code of Ethics, Scope of Practice, and Code of Conduct. It is my understanding that I am to uphold all 11 ethical principles in my work and in all contact with clients and/or patients, either employed or volunteering; and by signing this application, I agree to abide by these ethical and conduct standards. I understand that my registration and/or certification can be suspended and/or revoked if I violate any of these ethical and/or conduct standards.

Date Signed(Required)

Individual Registration Application Must submit all pages including the Release of Information form(Required)

Electronic Application Submitted

ACCBC Code of Ethics Must submit all pages Must be signed initialed and dated(Required)

ACCBC Code of Ethics Submitted with Application

Scope of Practice Must submit all pages Must be signed initialed and dated(Required)

Electronic Scope of Practice Submitted with Application

Code of Conduct Must submit all pages Must be signed initialed and dated(Required)

Electronic Code of Conduct Submitted with Application

Copy of Drivers License or valid Government Issued Photo ID Must be a clear copy(Required)

Max. file size: 15 MB.

Proof of Nine (9) Hours of Addiction Counselor Laws and Ethics Training(Required)

Drop files here or

Max. file size: 15 MB, Max. files: 5.

Credit Card(Required)

Card Details

Cardholder Name

Individual Registration (New)(Required)

Price:

Billing Address(Required)

Street Address City State ZIP Code

Use for Credit Card Authorization Only

Signature of Applicant Checklist(Required)

I have read, understand, and agree to the aforementioned policies and procedures and I have included all required documentation.

Date Signed_2(Required)

Individual Registration 10-21 A