Credential Application and/or Exam Fee Payments

Instructions

Credential Application Payment Form

Advanced and specialty credentials from Breining Institute demonstrate your commitment to providing quality care to your clients, beyond the basic certification or license you may need to work in your State or other jurisdiction.

After you have submitted your Credential Application, you may use this online form to provide payment information to Breining Institute.

Use this online form to submit your payment information using a VISA, MasterCard or Discover credit card. If you prefer to pay by check, please complete and print this form, and then send it to us by postal mail to: Breining Institute, 8894 Greenback Lane, Orangevale, California USA 95662

Payment Options:

You may use this form to authorize credit card payments for any of the following charges that are applicable to you, which you will select at the “Payment Information” section of this form.

Addiction Counselor Exam (ACE): $175
Private-practice / Clinical Supervisor (PCS) Exam: $175
Certified Case Manager Interventionist (CCMI) Application Fee: $75
Certified Case Manager Interventionist (CCMI) Exam Fee: $175

IMPORTANT NOTICE: Applications or exam requests that require payment will not be processed until payment is confirmed.

Applicant Info

Applicant Information

Full Name: *

Address: *

City:

State / Province: *

ZIP Code or Country Code: *

Country: *

Country (if not the United States):

Email Address: *

Confirm Email Address: *

Please re-enter your email address here

Primary Phone Number *

Payment Info

Payment Information

Credit Card Charge Authorization

Breining Institute is authorized to charge the above-selected amount(s) to the following credit card:

Please be careful to input all information carefully, in order to for us to promptly process your payment.

If you have made multiple selections, such as paying for the CCMI Application and CCMI Exam Fee, your card will be charged the total of the amounts selected.

Please double check to ensure you have selected only those items for which you wish to be charged.

Select the charges you wish to make below: *

Addiction Counselor Exam (ACE): $175

Private-practice / Clinical Supervisor (PCS) Exam: $175

Certified Case Manager Interventionist (CCMI) Application Fee: $75

Certified Case Manager Interventionist (CCMI) Exam Fee: $175

Credit Card: *

VISA

MasterCard

Discover

Credit Card Number: *

Credit Card Expiration Date *

Full Name on Credit Card: *

ATTESTATION

By submitting this form, I attest that the information I have provided above is true and authentic. I authorize Breining Institute to charge the above-selected amount(s). I attest that I will adhere to the applicable Code of Ethics, Code of Conduct, and Scope of Practice related to my credential. I understand that if at any time it is determined that the information provided is materially misrepresented, any fees which have been paid will be forfeited, and registration, certifications and/or credentials may be revoked.

Signature

Please carefully use this space to sign your name, which must match the signature we have on record in your credential file.

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