Credential Verification Request

An International Certificate is directly tied to a professional’s certification or license with an IC&RC member board. They are not free-standing certificates. IC&RC can only verify International Certificates for professionals that hold an eligible credential through an IC&RC member board.

Professionals should contact their IC&RC member board to determine if they hold an International Certificate before completing this form. The contact information for all member boards can be found online at: www.internationalcredentialing.org.

Fees:

Credential Verification: $10.00 USD

Name *

First Name Last Name

E-mail *

Phone Number *

- Area Code Phone Number

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

You must hold a credential or license through an IC&RC member boards in order to have an International Certificate for IC&RC to verify. If you are unsure if you hold an International Certificate, contact the IC&RC member board in your jursidiction. Contact information for all boards can be found at this link: http://www.internationalcredentialing.org/memberboards

IC&RC Member Board *

Credential to be verified: *

ICADC (Internationally Certified Alcohol and Drug Counelor) ICAADC (Internationally Certified Advanced Alcohol and Drug Counelor) ICCS (Internationally Certified Clinical Supervisor) ICCJP ((Internationally Certified Criminal Justice Addictions Professional) ICCDP (Internationally Certified Co-Occourring Disorders Professional) ICCDP-D (Internationally Certified Co-Occourring Disorders Professional-Diplomate) ICPS (Internationally Certified Prevention Specialist) ICPR (Internationally Certified Peer Recovery)

How would you like the verification to be sent? Please select one.

Email verification to:

Mail verification to:

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Attention to:

Would you like an additional copy?

Yes No

If you would like an additional copy, please indicate how you would like the additional copy sent. Please select one.

Email copy to:

Mail copy to:

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Attention to:

Form of Payment *

Check or Money Order Made out to IC&RC Credit Card

My Products *

Credential Verification $ 10.00

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year
Billing Address
Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Please print this form and return it to IC&RC with a check or money order made out to IC&RC to the address below:

IC&RC

298 S. Progress AVe.

Harrisburg, PA 17109

USA

Due to state specific policies and procedures, IC&RC is unable to verify International Certificates for your jurisdiction. Please contact the IC&RC member board in your jurisdiction to request an International Certificate Verification. Contact information for all IC&RC member boards can be found at this link: http://www.internationalcredentialing.org/memberboards.

International Certificate Verification Request