Maryland Addiction Professionals

MARYLAND ADDICTIONS PROFESSIONAL CERTIFICATION BOARD (MAPCB)

10807 Falls Rd., PO Box #1376 Brooklandville, Maryland 21022 Phone: 866-537-5340

RECERTIFICATION APPLICATION TYPE: : CCDC CCS CCJP (Please circle credential being renewed. If more than one, circle each and send $75 for each being renewed. Only $50 for CCS if it accompanies a CCDC or CCJP renewal) Date: ______NAME______CERTIFICATION #______RECERT DATE______SOCIAL SECURITY#______ADDRESS______CITY______STATE______ZIPCODE______TELEPHONE______HOME ______WORK EMAIL______

Please answer “yes” or “no” to the following questions for incidents since your last certification period and return this form with your $75.00 check to the above address.

1. Has any State certifying or Disciplinary Board or a comparable body in the Armed Services denied your application for certification, licensure, reinstatement or renewal or taken action against your certification or licensure, including, but not limited to reprimand, suspension or revocation? ______Have you ever surrendered or failed to renew a licensure or certification in any State? ______2. Are there any outstanding complaints, investigations, or charges against you in any State by any licensing, certifying or disciplinary Board, or a comparable body in the Armed Services? ______3. Have you any physical or mental illness that impairs you ability to practice your profession? ______4. Have you ever plead guilty, nolo contendere or been convicted of, or received probation before judgment of any criminal act (excluding traffic violations)? ______5. Have you ever plead guilty, nolo contendere, or been convicted of or received probation before judgment of driving while intoxicated or of a controlled dangerous substance offense? ______6. Has any hospital or related health care institution or employer denied any application for privileges of employment, failed to renew your privileges or contract or limited, restricted, suspended, revoked or terminated your privileges or contract for any reason related to your practice? ______7. Have the conditions of your employment been affected by any termination of employment, suspension, or probation for any reasons related to your practice? ______8. Has a malpractice suit been filed against you or has a claim for damages been settled or awarded against you? ______

Please sign and attach a detailed explanation for any questions answered “YES”.

SIGNATURE______DATE______