Board Membership Application | Maryland Addiction and Behavioral-health Professionals Certification Board

Identifying Information

First

Middle

Last

Birthdate

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Home Phone

Employer Information

Employer Name

Work Phone

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Current Position / Title

Please give a brief description of your employment duties

Professional Information

Why do you wish to become a MABPCB Board Member?

What is your current certification / State License?

Date Received

Expiration Date

Membership in Professional Societies or Associations

Professional References

Reference 1

Professionals Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Clinician Phone

Length of Association

Reference 2

Professionals Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Clinician Phone

Length of Association

Reference 3

Professionals Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Clinician Phone

Length of Association

If you previously served with MABPCB, please give a summary of the dates you served and the reason you resigned

Resume

One file only.
100 MB limit.
Allowed types: pdf.

STATEMENT OF RESPONSIBILITY

I fully understand that any significant misstatement in or omission from this application constitutes cause for denial of appointment to the Certification Board. All information submitted in this application is true to the best of my knowledge and belief. In completing this application for appointment with the Certification Board, I agree to be bound by the terms of the MABPCB Ethical Policy before, during and after my possible selection to become a member.

As an applicant for membership, I agree to produce adequate information and/or documentation for proper evaluation of my professional competence, character, ethical standards and other qualifications in order to resolve any questions regarding my qualifications.

I also accept the responsibility to actively serve on the Certification Board for a full-term of two years. I accept the responsibility to actively serve on at least one subcommittee of the Certification Board. I also understand my participation at all bi-monthly Certification Board meetings is required.

Signature (type name)