AUTHORIZATION AND RELEASE FORM
I hereby authorize the Addiction Professionals Certification Board, Inc. to make any inquiry of any agency, facility, organization or individual for any and all additional information which might be necessary to fully and properly evaluate my application for the Certified Clinical Supervisor).
I hereby release and hold harmless the Addiction Professionals Certification Board, Inc., its Board of Directors, its Officers, its employees, servants, and agents from any and all manner of suits, actions, claims, and judgments which might arise from such efforts to further document the statements and claims I have made in this application or in the processing or consideration of same.
I further acknowledge, understand, and agree that any falsification or misrepresentation of information by myself or others regarding experience and/or qualifications will be sufficient reason for disapproval of my application or for withdrawal of the credential at a later date.
I understand that evaluations on me which are submitted by supervisors and/or colleagues are confidential. I hereby relinquish my right to review these evaluations.
I also affirm that I conform to the Ethical Standards as described in the requirements for credentialing
STATEMENT OF UNDERSTANDING
I hereby apply for certification to the Addiction Professionals Certification Board, Inc. I understand that approval of my application depends upon my successfully completing the assessment of competency as established by the Board, including submission of all required references and successful completion of a practicum in an approved treatment facility. I also understand that for research and statistical purposes only, the data from this application may be used in a non-identifying manner.
I also understand this credential is designed to recognize individuals working with chemically dependent clients and is not restricted to primary alcohol/drug counselors.