Alcohol and Drug Counseling - Cert Request

Alcohol and Drug Counseling Certificate
Application Form

Please turn in application only if you have completed the program.

I have successfully completed the required courses for the Certificate in Alcohol & Drug Counseling and am thereby entitled to receive the certificate. (*Student must have an overall grade point average of 2.5 or better to receive the certificate.)

Students: This certificate application is a record of your achievement. Like a grade report, it provides documentation for the certificate award. After you have completed all requirements, fill in this form and click the Submit Application button below.

Student Information


[Name as it should appear on the printed Certificate]

[Include Street Address, City, State and Zip Code]

Course Information

Required Course(s)Term Completed
Elective Courses (one of the following)

Student Signature