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APPLICATION FOR CEU PROVIDER Instructions: fill out the form below completely and include your application fee of $150 by check or money order made payable to ACADC.  Mail to ACADC Institute, PO Box 8604, Redlands, CA 92375.  If you are not approved, your fee will be returned to you in its entirety.

NAME _______________________________________________________________________________

ADDRESS ____________________________________________________________________________

TEL _________________________________________________________________________________

MY QUALIFICATIONS (Please list degrees, certifications, and certificates of completion)

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MY EXPERIENCE: ______________________________________________________________________

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REFERENCES: 

NAME____________________________     PHONE NUMBER __________________________

NAME____________________________     PHONE NUMBER __________________________

NAME_____________________________   PHONE NUMBER __________________________

I hereby apply to be considered for CEU Provider for the Association of Christian Alcohol & Drug Counselors Institute on the ________ day, ___________month of ____________ year AD.

Signature ____________________________________________________