{"id":1323,"date":"2015-10-09T10:41:57","date_gmt":"2015-10-09T17:41:57","guid":{"rendered":"http:\/\/www.breining.edu\/?page_id=1323"},"modified":"2024-08-30T08:41:34","modified_gmt":"2024-08-30T15:41:34","slug":"credential-renewal-application-online","status":"publish","type":"page","link":"https:\/\/www.breining.edu\/index.php\/professional-certification\/credential-renewal-application-online\/","title":{"rendered":"Credential Renewal Application: Online"},"content":{"rendered":"<form method=\"post\" enctype=\"multipart\/form-data\" id=\"vfbp-form-97\" class=\"vfbp-form\"><div style=\"display:none;\"><label for=\"vfbp-EMAIL-AN8fuQyoDLXem\">If you are human, leave this field blank.<\/label><input size=\"25\" autocomplete=\"off\" type=\"text\" name=\"vfbp-EMAIL-AN8fuQyoDLXem\" value=\"\" id=\"\"><\/div><input type=\"hidden\" name=\"_vfb-timestamp-97\" value=\"1775599308\" id=\"\"><input type=\"hidden\" name=\"_vfb-form-id\" value=\"97\" id=\"\"><section class=\"vfb-page-section\"><h3 class=\"vfb-page-title\">Instructions<\/h3><div class=\"vfb-col-12 vfb-fieldType-page-break\" id=\"vfbField2945\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-instructions\" id=\"vfbField2946\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2946\" class=\"vfb-control-label\">Professional Credential Renewal Information<\/label><div class=\"\"><h4><span style=\"color: #993300;\">Your 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.<\/span><\/h4>\n<ul>\n<li>You may use this form to RENEW all of your Breining Institute credentials up to one year prior to your renewal date.<\/li>\n<li>You may also UPGRADE your current RAS and\/or CCMI Credentials at the same time you renew, using this form.<\/li>\n<li>Please be prepared to upload a copy of a government-issued ID card and a recent passport-type photo of yourself (facing forward, no hats or sunglasses).<\/li>\n<\/ul>\n<hr noshade=\"noshade\" size=\"5\" \/>\n<h4><span style=\"color: #800000;\">Renewal Fee Options:<\/span><\/h4>\n<ul>\n<li><strong>ON-TIME RENEWAL: <\/strong>\n<ul>\n<li><strong>$275 &#8211; <\/strong>If you are renewing on-time, you will pay the one renewal fee to renew all of your credentials. Renewal is for a two-year period from the date of your current credential. You may renew credentials up to one year before your renewal date.<\/li>\n<\/ul>\n<\/li>\n<li><strong>LATE RENEWAL:<\/strong>\n<ul>\n<li><strong>$375 &#8211; <\/strong>If you are renewing late, you will pay the one fee to renew all of your credentials. Renewal is for a two-year period from the date that we renew your credential.<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<h4><span style=\"color: #800000;\">Optional Discount for CE Completion:<\/span><\/h4>\n<ul>\n<li><strong>$50 discount<\/strong> is available if you have completed a Breining Institute 30-hour or 40-hour CE Bundle for this renewal.<\/li>\n<li>You may complete the same Bundle that you completed for a previous renewal. For example, if you completed the Telehealth Bundle for a previous credential renewal, you may complete the Telehealth Bundle, again, for this renewal.<\/li>\n<li>If you have not already completed a 30-hour CE Bundle, they are available at this link: <a href=\"https:\/\/www.breining.edu\/index.php\/online-continuing-education-ce\/\">Online Continuing Education (CE)<\/a><\/li>\n<\/ul>\n<hr noshade=\"noshade\" size=\"5\" \/>\n<p>IMPORTANT NOTICE TO CALIFORNIA COUNSELORS: Renewal of your internationally-awarded Breining Institute credentials is separate from the requirement for California SUD counselors to be registered or maintain entry-level certification with CADTP, CAADE or CCAPP.<\/p>\n<\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><\/section><section class=\"vfb-page-section\"><h3 class=\"vfb-page-title\">Applicant Info<\/h3><div class=\"vfb-col-12 vfb-fieldType-page-break\" id=\"vfbField2947\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-form-group vfb-col-12\"><div><div class=\"\"><\/div><span class=\"vfb-help-block\"><h3><span style=\"color: #800000;\">Credential Holder Information<\/span><\/h3><\/span><\/div><\/div><div class=\"vfb-col-12 vfb-fieldType-heading\" id=\"vfbField2948\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField2949\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2949\" class=\"vfb-control-label\">Full Name: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-2949\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-2949\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-date\" id=\"vfbField2950\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2950\" class=\"vfb-control-label\">Date of Birth <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-2950\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" data-provide=\"datepicker\" type=\"text\" name=\"vfb-field-2950\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField2951\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2951\" class=\"vfb-control-label\">Address: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-2951\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-2951\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField2952\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2952\" class=\"vfb-control-label\">City:<\/label><div><input id=\"vfb-field-2952\" class=\"vfb-form-control\" placeholder=\"\" type=\"text\" name=\"vfb-field-2952\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField2953\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2953\" class=\"vfb-control-label\">State \/ Province: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-2953\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-2953\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField2954\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2954\" class=\"vfb-control-label\">ZIP Code or Country Code: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-2954\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-2954\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-select\" id=\"vfbField2955\"><label for=\"vfb-field-2955\" class=\"vfb-control-label\">Country: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><div class=\"vfb-form-group\"><select id=\"vfb-field-2955\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" name=\"vfb-field-2955\"><option value=\"United States\">United States<\/option><option value=\"Other\">Other<\/option><\/select><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField2956\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2956\" class=\"vfb-control-label\">Country (if not the United States):<\/label><div><input id=\"vfb-field-2956\" class=\"vfb-form-control\" placeholder=\"\" type=\"text\" name=\"vfb-field-2956\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-email\" id=\"vfbField2957\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2957\" class=\"vfb-control-label\">Email Address: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-2957\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"email\" name=\"vfb-field-2957\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-email\" id=\"vfbField2958\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2958\" class=\"vfb-control-label\">Confirm Email Address: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">Please re-enter your email address here<\/span><input id=\"vfb-field-2958\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" data-vfb-equalto=\"#vfb-field-2957\" type=\"email\" name=\"vfb-field-2958\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-phone\" id=\"vfbField2959\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2959\" class=\"vfb-control-label\">Primary Phone Number <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-2959\" class=\"vfb-form-control vfb-intl-phone\" placeholder=\"\" required=\"required\" type=\"tel\" name=\"vfb-field-2959\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><\/section><section class=\"vfb-page-section\"><h3 class=\"vfb-page-title\">ID and Photo<\/h3><div class=\"vfb-col-12 vfb-fieldType-page-break\" id=\"vfbField3336\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-instructions\" id=\"vfbField3341\"><div class=\"vfb-form-group\"><label for=\"vfb-field-3341\" class=\"vfb-control-label\"><\/label><div class=\"\"><h3><span style=\"color: #800000;\">Government-issued ID Card Upload<\/span><\/h3>\n<ul>\n<li>Upload a copy of an identification card which includes your photo, such as a drivers license or passport or similar ID card that is issued by a government agency.<\/li>\n<li>The copy of the ID should be in PDF or JPG format.<\/li>\n<li>This ID card will be used for our internal identification verification purposes only.<\/li>\n<\/ul>\n<h4><span style=\"color: #339966;\"><strong>If you are unable to upload a copy of your ID card here, please send it to us by email at college@breining.edu<\/strong><\/span><\/h4>\n<\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-file-upload\" id=\"vfbField2960\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2960\" class=\"vfb-control-label\">Government-issued ID Card Upload<\/label><div><input id=\"vfb-field-2960\" class=\"vfb-form-control vfb-file-input\" placeholder=\"\" data-max-file-size=\"5000\" data-max-file-count=\"1\" data-allowed-file-extensions=\"pdf,jpg,jpeg\" type=\"file\" name=\"vfb-field-2960\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-instructions\" id=\"vfbField3340\"><div class=\"vfb-form-group\"><label for=\"vfb-field-3340\" class=\"vfb-control-label\"><\/label><div class=\"\"><h3><span style=\"color: #339966;\"><a href=\"https:\/\/www.breining.edu\/wp-content\/uploads\/2024\/08\/photo-guidelines-200.jpg\"><img loading=\"lazy\" decoding=\"async\" class=\"alignnone size-full wp-image-33164\" src=\"https:\/\/www.breining.edu\/wp-content\/uploads\/2024\/08\/photo-guidelines-200.jpg\" alt=\"\" width=\"200\" height=\"164\" \/><\/a><br \/>\n<span style=\"color: #800000;\">Current Photograph Upload<\/span><\/span><\/h3>\n<ul>\n<li>Upload a current photo of you.<\/li>\n<li>Photo must be in color.<\/li>\n<li>Facing forward, look straight to the camera.<\/li>\n<li>No hats or sunglasses.<\/li>\n<li>The photo may be taken using your smart phone or similar device.<\/li>\n<\/ul>\n<h4><span style=\"color: #339966;\"><strong>If you are unable to upload the photo here, please send it to us by email at college@breining.edu<\/strong><\/span><\/h4>\n<p>This photo will be used on our publicly-accessible website page that verifies the award of your credential(s), and we will include it on your credential renewal certificate. In consideration of issuance of the credential referenced in this application, you expressly agree that the photo you submit and your likeness contained therein may be included in the Breining Institute &#8220;International Credential Verification (ICV) System&#8221; and posted on the credential verification pages of Breining Institute websites. By submitting the photo, you hereby release and discharge Breining Institute from any and all actions, claims and demands of any nature which you may have at any time now or in the future arising out of or related to the rights to the photo granted herein or your likeness.<\/p>\n<p><strong>Online Verification of Credentials<\/strong><\/p>\n<p>Current credential status may be verified online through the Breining Institute International Credential Verification (ICV) System, Certified \/ Credentialed Counselors (CCCo), at this link: <a href=\"https:\/\/ccco.breining.edu\/\" target=\"_blank\" rel=\"noopener noreferrer\">https:\/\/ccco.breining.edu\/<\/a><\/p>\n<\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-file-upload\" id=\"vfbField2961\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2961\" class=\"vfb-control-label\">Current Photograph Upload<\/label><div><input id=\"vfb-field-2961\" class=\"vfb-form-control vfb-file-input\" placeholder=\"\" data-max-file-size=\"5000\" data-max-file-count=\"1\" data-allowed-file-extensions=\"pdf,jpg,jpeg\" type=\"file\" name=\"vfb-field-2961\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><\/section><section class=\"vfb-page-section\"><h3 class=\"vfb-page-title\">Employment Info<\/h3><div class=\"vfb-col-12 vfb-fieldType-page-break\" id=\"vfbField3339\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-form-group vfb-col-12\"><div><div class=\"\"><\/div><span class=\"vfb-help-block\"><h3><span style=\"color: #800000;\">Employment Information<\/span><\/h3>\r\n<ul>\r\n \t<li>This will include the organization or individuals that currently employ you, or if you're unemployed or retired, where you previously worked most recently.<\/li>\r\n \t<li>This may include either a paid or volunteer position.<\/li>\r\n \t<li>If you are an independent practitioner, or otherwise self-employed, provide the primary contact information for your business.<\/li>\r\n<\/ul><\/span><\/div><\/div><div class=\"vfb-col-12 vfb-fieldType-heading\" id=\"vfbField3100\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-radio\" id=\"vfbField3101\"><label for=\"vfb-field-3101\" class=\"vfb-control-label\">Employment status <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><div class=\"vfb-radio\"><label><input id=\"vfb-field-3101-0\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-3101\" value=\"Currently employed\">Currently employed<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-3101-1\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-3101\" value=\"Independent practitioner or self-employed\">Independent practitioner or self-employed<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-3101-2\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-3101\" value=\"Unemployed\">Unemployed<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-3101-3\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-3101\" value=\"Retired\">Retired<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-3101-4\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-3101\" value=\"Other\">Other<\/label><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField3103\"><div class=\"vfb-form-group\"><label for=\"vfb-field-3103\" class=\"vfb-control-label\">Name of current or most recent company or employer <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-3103\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-3103\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-address\" id=\"vfbField3102\"><div class=\"vfb-form-group\"><label for=\"vfb-field-3102\" class=\"vfb-control-label\">Company address <span class=\"vfb-required-asterisk\">*<\/span><\/label><div class=\"vfb-address-block\" id=\"vfb-field-3102\"><div class=\"vfb-form-group\" style=\"\"><input id=\"vfb-field-3102-address-1\" class=\"vfb-form-control vfb-addresspart-address-1\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-3102[address-1]\"><\/div><div class=\"vfb-form-group\" style=\"\"><label for=\"vfb-field-3102-address-2\" class=\"vfb-address-label\">Apt, suite, etc.<\/label><input id=\"vfb-field-3102-address-2\" class=\"vfb-form-control vfb-addresspart-address-2\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-3102[address-2]\"><\/div><div class=\"vfb-form-group\" style=\"\"><label for=\"vfb-field-3102-country\" class=\"vfb-address-label\">Country<\/label><select id=\"vfb-field-3102-country\" class=\"vfb-form-control vfb-addresspart-country\" placeholder=\"\" required=\"required\" name=\"vfb-field-3102[country]\"><option value=\"US\" selected='selected'>United States (US)<\/option><option value=\"GB\">United Kingdom (UK)<\/option><option value=\"CA\">Canada<\/option><option value=\"AU\">Australia<\/option><option value=\"\">---<\/option><option value=\"AF\">Afghanistan<\/option><option value=\"AX\">&#197;land Islands<\/option><option value=\"AL\">Albania<\/option><option value=\"DZ\">Algeria<\/option><option value=\"AD\">Andorra<\/option><option value=\"AO\">Angola<\/option><option value=\"AI\">Anguilla<\/option><option value=\"AQ\">Antarctica<\/option><option value=\"AG\">Antigua and Barbuda<\/option><option value=\"AR\">Argentina<\/option><option value=\"AM\">Armenia<\/option><option value=\"AW\">Aruba<\/option><option value=\"AS\">American Samoa<\/option><option value=\"AT\">Austria<\/option><option value=\"AZ\">Azerbaijan<\/option><option value=\"BS\">Bahamas<\/option><option value=\"BH\">Bahrain<\/option><option value=\"BD\">Bangladesh<\/option><option value=\"BB\">Barbados<\/option><option value=\"BY\">Belarus<\/option><option value=\"BE\">Belgium<\/option><option value=\"PW\">Belau<\/option><option value=\"BZ\">Belize<\/option><option value=\"BJ\">Benin<\/option><option value=\"BM\">Bermuda<\/option><option value=\"BT\">Bhutan<\/option><option value=\"BO\">Bolivia<\/option><option value=\"BQ\">Bonaire, Saint Eustatius and Saba<\/option><option value=\"BA\">Bosnia and Herzegovina<\/option><option value=\"BW\">Botswana<\/option><option value=\"BV\">Bouvet Island<\/option><option value=\"BR\">Brazil<\/option><option value=\"IO\">British Indian Ocean Territory<\/option><option value=\"VG\">British Virgin Islands<\/option><option value=\"BN\">Brunei<\/option><option value=\"BG\">Bulgaria<\/option><option value=\"BF\">Burkina Faso<\/option><option value=\"BI\">Burundi<\/option><option value=\"KH\">Cambodia<\/option><option value=\"CM\">Cameroon<\/option><option value=\"CV\">Cape Verde<\/option><option value=\"KY\">Cayman Islands<\/option><option value=\"CF\">Central African Republic<\/option><option value=\"TD\">Chad<\/option><option value=\"CL\">Chile<\/option><option value=\"CN\">China<\/option><option value=\"CX\">Christmas Island<\/option><option value=\"CC\">Cocos (Keeling) Islands<\/option><option value=\"CO\">Colombia<\/option><option value=\"KM\">Comoros<\/option><option value=\"CG\">Congo (Brazzaville)<\/option><option value=\"CD\">Congo (Kinshasa)<\/option><option value=\"CK\">Cook Islands<\/option><option value=\"CR\">Costa Rica<\/option><option value=\"HR\">Croatia<\/option><option value=\"CU\">Cuba<\/option><option value=\"CW\">Cura&Ccedil;ao<\/option><option value=\"CY\">Cyprus<\/option><option value=\"CZ\">Czech Republic<\/option><option value=\"DK\">Denmark<\/option><option value=\"DJ\">Djibouti<\/option><option value=\"DM\">Dominica<\/option><option value=\"DO\">Dominican Republic<\/option><option value=\"EC\">Ecuador<\/option><option value=\"EG\">Egypt<\/option><option value=\"SV\">El Salvador<\/option><option value=\"GQ\">Equatorial Guinea<\/option><option value=\"ER\">Eritrea<\/option><option value=\"EE\">Estonia<\/option><option value=\"ET\">Ethiopia<\/option><option value=\"FK\">Falkland Islands<\/option><option value=\"FO\">Faroe Islands<\/option><option value=\"FJ\">Fiji<\/option><option value=\"FI\">Finland<\/option><option value=\"FR\">France<\/option><option value=\"GF\">French Guiana<\/option><option value=\"PF\">French Polynesia<\/option><option value=\"TF\">French Southern Territories<\/option><option value=\"GA\">Gabon<\/option><option value=\"GM\">Gambia<\/option><option value=\"GE\">Georgia<\/option><option value=\"DE\">Germany<\/option><option value=\"GH\">Ghana<\/option><option value=\"GI\">Gibraltar<\/option><option value=\"GR\">Greece<\/option><option value=\"GL\">Greenland<\/option><option value=\"GD\">Grenada<\/option><option value=\"GP\">Guadeloupe<\/option><option value=\"GT\">Guatemala<\/option><option value=\"GG\">Guernsey<\/option><option value=\"GN\">Guinea<\/option><option value=\"GW\">Guinea-Bissau<\/option><option value=\"GY\">Guyana<\/option><option value=\"HT\">Haiti<\/option><option value=\"HM\">Heard Island and McDonald Islands<\/option><option value=\"HN\">Honduras<\/option><option value=\"HK\">Hong Kong<\/option><option value=\"HU\">Hungary<\/option><option value=\"IS\">Iceland<\/option><option value=\"IN\">India<\/option><option value=\"ID\">Indonesia<\/option><option value=\"IR\">Iran<\/option><option value=\"IQ\">Iraq<\/option><option value=\"IE\">Republic of Ireland<\/option><option value=\"IM\">Isle of Man<\/option><option value=\"IL\">Israel<\/option><option value=\"IT\">Italy<\/option><option value=\"CI\">Ivory Coast<\/option><option value=\"JM\">Jamaica<\/option><option value=\"JP\">Japan<\/option><option value=\"JE\">Jersey<\/option><option value=\"JO\">Jordan<\/option><option value=\"KZ\">Kazakhstan<\/option><option value=\"KE\">Kenya<\/option><option value=\"KI\">Kiribati<\/option><option value=\"KW\">Kuwait<\/option><option value=\"KG\">Kyrgyzstan<\/option><option value=\"LA\">Laos<\/option><option value=\"LV\">Latvia<\/option><option value=\"LB\">Lebanon<\/option><option value=\"LS\">Lesotho<\/option><option value=\"LR\">Liberia<\/option><option value=\"LY\">Libya<\/option><option value=\"LI\">Liechtenstein<\/option><option value=\"LT\">Lithuania<\/option><option value=\"LU\">Luxembourg<\/option><option value=\"MO\">Macao S.A.R., China<\/option><option value=\"MK\">Macedonia<\/option><option value=\"MG\">Madagascar<\/option><option value=\"MW\">Malawi<\/option><option value=\"MY\">Malaysia<\/option><option value=\"MV\">Maldives<\/option><option value=\"ML\">Mali<\/option><option value=\"MT\">Malta<\/option><option value=\"MH\">Marshall Islands<\/option><option value=\"MQ\">Martinique<\/option><option value=\"MR\">Mauritania<\/option><option value=\"MU\">Mauritius<\/option><option value=\"YT\">Mayotte<\/option><option value=\"MX\">Mexico<\/option><option value=\"FM\">Micronesia<\/option><option value=\"MD\">Moldova<\/option><option value=\"MC\">Monaco<\/option><option value=\"MN\">Mongolia<\/option><option value=\"ME\">Montenegro<\/option><option value=\"MS\">Montserrat<\/option><option value=\"MA\">Morocco<\/option><option value=\"MZ\">Mozambique<\/option><option value=\"MM\">Myanmar<\/option><option value=\"NA\">Namibia<\/option><option value=\"NR\">Nauru<\/option><option value=\"NP\">Nepal<\/option><option value=\"NL\">Netherlands<\/option><option value=\"AN\">Netherlands Antilles<\/option><option value=\"NC\">New Caledonia<\/option><option value=\"NZ\">New Zealand<\/option><option value=\"NI\">Nicaragua<\/option><option value=\"NE\">Niger<\/option><option value=\"NG\">Nigeria<\/option><option value=\"NU\">Niue<\/option><option value=\"NF\">Norfolk Island<\/option><option value=\"KP\">North Korea<\/option><option value=\"NO\">Norway<\/option><option value=\"OM\">Oman<\/option><option value=\"PK\">Pakistan<\/option><option value=\"PS\">Palestinian Territory<\/option><option value=\"PA\">Panama<\/option><option value=\"PG\">Papua New Guinea<\/option><option value=\"PY\">Paraguay<\/option><option value=\"PE\">Peru<\/option><option value=\"PH\">Philippines<\/option><option value=\"PN\">Pitcairn<\/option><option value=\"PL\">Poland<\/option><option value=\"PT\">Portugal<\/option><option value=\"QA\">Qatar<\/option><option value=\"RE\">Reunion<\/option><option value=\"RO\">Romania<\/option><option value=\"RU\">Russia<\/option><option value=\"RW\">Rwanda<\/option><option value=\"BL\">Saint Barth&eacute;lemy<\/option><option value=\"SH\">Saint Helena<\/option><option value=\"KN\">Saint Kitts and Nevis<\/option><option value=\"LC\">Saint Lucia<\/option><option value=\"MF\">Saint Martin (French part)<\/option><option value=\"SX\">Saint Martin (Dutch part)<\/option><option value=\"PM\">Saint Pierre and Miquelon<\/option><option value=\"VC\">Saint Vincent and the Grenadines<\/option><option value=\"SM\">San Marino<\/option><option value=\"ST\">S&atilde;o Tom&eacute; and Pr&iacute;ncipe<\/option><option value=\"SA\">Saudi Arabia<\/option><option value=\"SN\">Senegal<\/option><option value=\"RS\">Serbia<\/option><option value=\"SC\">Seychelles<\/option><option value=\"SL\">Sierra Leone<\/option><option value=\"SG\">Singapore<\/option><option value=\"SK\">Slovakia<\/option><option value=\"SI\">Slovenia<\/option><option value=\"SB\">Solomon Islands<\/option><option value=\"SO\">Somalia<\/option><option value=\"ZA\">South Africa<\/option><option value=\"GS\">South Georgia\/Sandwich Islands<\/option><option value=\"KR\">South Korea<\/option><option value=\"SS\">South Sudan<\/option><option value=\"ES\">Spain<\/option><option value=\"LK\">Sri Lanka<\/option><option value=\"SD\">Sudan<\/option><option value=\"SR\">Suriname<\/option><option value=\"SJ\">Svalbard and Jan Mayen<\/option><option value=\"SZ\">Swaziland<\/option><option value=\"SE\">Sweden<\/option><option value=\"CH\">Switzerland<\/option><option value=\"SY\">Syria<\/option><option value=\"TW\">Taiwan<\/option><option value=\"TJ\">Tajikistan<\/option><option value=\"TZ\">Tanzania<\/option><option value=\"TH\">Thailand<\/option><option value=\"TL\">Timor-Leste<\/option><option value=\"TG\">Togo<\/option><option value=\"TK\">Tokelau<\/option><option value=\"TO\">Tonga<\/option><option value=\"TT\">Trinidad and Tobago<\/option><option value=\"TN\">Tunisia<\/option><option value=\"TR\">Turkey<\/option><option value=\"TM\">Turkmenistan<\/option><option value=\"TC\">Turks and Caicos Islands<\/option><option value=\"TV\">Tuvalu<\/option><option value=\"UG\">Uganda<\/option><option value=\"UA\">Ukraine<\/option><option value=\"AE\">United Arab Emirates<\/option><option value=\"UY\">Uruguay<\/option><option value=\"UZ\">Uzbekistan<\/option><option value=\"VU\">Vanuatu<\/option><option value=\"VA\">Vatican<\/option><option value=\"VE\">Venezuela<\/option><option value=\"VN\">Vietnam<\/option><option value=\"WF\">Wallis and Futuna<\/option><option value=\"EH\">Western Sahara<\/option><option value=\"WS\">Western Samoa<\/option><option value=\"YE\">Yemen<\/option><option value=\"ZM\">Zambia<\/option><option value=\"ZW\">Zimbabwe<\/option><\/select><\/div><div class=\"vfb-form-group\" style=\"\"><label for=\"vfb-field-3102-city\" class=\"vfb-address-label\">City<\/label><input id=\"vfb-field-3102-city\" class=\"vfb-form-control vfb-addresspart-city\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-3102[city]\"><\/div><div class=\"vfb-form-group\" style=\"\"><label for=\"vfb-field-3102-province\" class=\"vfb-address-label\">State<\/label><select id=\"vfb-field-3102-province\" class=\"vfb-form-control vfb-addresspart-province\" placeholder=\"\" required=\"required\" name=\"vfb-field-3102[province]\"><option value=\"\"><\/option><option value=\"AL\">Alabama<\/option><option value=\"AK\">Alaska<\/option><option value=\"AZ\">Arizona<\/option><option value=\"AR\">Arkansas<\/option><option value=\"CA\">California<\/option><option value=\"CO\">Colorado<\/option><option value=\"CT\">Connecticut<\/option><option value=\"DE\">Delaware<\/option><option value=\"DC\">District Of Columbia<\/option><option value=\"FL\">Florida<\/option><option value=\"GA\">Georgia<\/option><option value=\"HI\">Hawaii<\/option><option value=\"ID\">Idaho<\/option><option value=\"IL\">Illinois<\/option><option value=\"IN\">Indiana<\/option><option value=\"IA\">Iowa<\/option><option value=\"KS\">Kansas<\/option><option value=\"KY\">Kentucky<\/option><option value=\"LA\">Louisiana<\/option><option value=\"ME\">Maine<\/option><option value=\"MD\">Maryland<\/option><option value=\"MA\">Massachusetts<\/option><option value=\"MI\">Michigan<\/option><option value=\"MN\">Minnesota<\/option><option value=\"MS\">Mississippi<\/option><option value=\"MO\">Missouri<\/option><option value=\"MT\">Montana<\/option><option value=\"NE\">Nebraska<\/option><option value=\"NV\">Nevada<\/option><option value=\"NH\">New Hampshire<\/option><option value=\"NJ\">New Jersey<\/option><option value=\"NM\">New Mexico<\/option><option value=\"NY\">New York<\/option><option value=\"NC\">North Carolina<\/option><option value=\"ND\">North Dakota<\/option><option value=\"OH\">Ohio<\/option><option value=\"OK\">Oklahoma<\/option><option value=\"OR\">Oregon<\/option><option value=\"PA\">Pennsylvania<\/option><option value=\"RI\">Rhode Island<\/option><option value=\"SC\">South Carolina<\/option><option value=\"SD\">South Dakota<\/option><option value=\"TN\">Tennessee<\/option><option value=\"TX\">Texas<\/option><option value=\"UT\">Utah<\/option><option value=\"VT\">Vermont<\/option><option value=\"VA\">Virginia<\/option><option value=\"WA\">Washington<\/option><option value=\"WV\">West Virginia<\/option><option value=\"WI\">Wisconsin<\/option><option value=\"WY\">Wyoming<\/option><option value=\"AA\">Armed Forces (AA)<\/option><option value=\"AE\">Armed Forces (AE)<\/option><option value=\"AP\">Armed Forces (AP)<\/option><option value=\"AS\">American Samoa<\/option><option value=\"GU\">Guam<\/option><option value=\"MP\">Northern Mariana Islands<\/option><option value=\"PR\">Puerto Rico<\/option><option value=\"UM\">US Minor Outlying Islands<\/option><option value=\"VI\">US Virgin Islands<\/option><\/select><\/div><div class=\"vfb-form-group\" style=\"\"><label for=\"vfb-field-3102-zip\" class=\"vfb-address-label\">Zip code<\/label><input id=\"vfb-field-3102-zip\" class=\"vfb-form-control vfb-addresspart-zip\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-3102[zip]\"><\/div><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField3197\"><div class=\"vfb-form-group\"><label for=\"vfb-field-3197\" class=\"vfb-control-label\">Website address of company<\/label><div><input id=\"vfb-field-3197\" class=\"vfb-form-control\" placeholder=\"\" type=\"text\" name=\"vfb-field-3197\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><\/section><section class=\"vfb-page-section\"><h3 class=\"vfb-page-title\">Credential Info<\/h3><div class=\"vfb-col-12 vfb-fieldType-page-break\" id=\"vfbField2962\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-form-group vfb-col-12\"><div><div class=\"\">Credential Information and Attestations<\/div><\/div><\/div><div class=\"vfb-col-12 vfb-fieldType-heading\" id=\"vfbField2963\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-checkbox\" id=\"vfbField2964\"><label for=\"vfb-field-2964\" class=\"vfb-control-label\">Current Breining Credentials <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">Please select all credentials that you currently hold.<\/span><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-2964-0\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-2964\" required=\"required\" type=\"checkbox\" name=\"vfb-field-2964[0]\" value=\"1\">Registered Addiction Specialist (RAS)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-2964-1\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-2964\" type=\"checkbox\" name=\"vfb-field-2964[1]\" value=\"1\">Registered Addiction Specialist - Level II (RAS II)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-2964-2\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-2964\" type=\"checkbox\" name=\"vfb-field-2964[2]\" value=\"1\">Registered Addiction Specialist - Level III (RAS III)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-2964-3\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-2964\" type=\"checkbox\" name=\"vfb-field-2964[3]\" value=\"1\">Masters Level - Registered Addiction Specialist (M-RAS)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-2964-4\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-2964\" type=\"checkbox\" name=\"vfb-field-2964[4]\" value=\"1\">Clinical Supervisor Credential (CSC)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-2964-5\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-2964\" type=\"checkbox\" name=\"vfb-field-2964[5]\" value=\"1\">Master Counselor in Addictions (MCA)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-2964-6\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-2964\" type=\"checkbox\" name=\"vfb-field-2964[6]\" value=\"1\">Certified Womens Treatment Specialist (CWTS)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-2964-7\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-2964\" type=\"checkbox\" name=\"vfb-field-2964[7]\" value=\"1\">Medication-Assisted Treatment Counselor (MATC)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-2964-8\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-2964\" type=\"checkbox\" name=\"vfb-field-2964[8]\" value=\"1\">Forensic Addiction Counselor (FAC)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-2964-9\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-2964\" type=\"checkbox\" name=\"vfb-field-2964[9]\" value=\"1\">Certified Co-occurring Disorders Specialist (CCDS)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-2964-10\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-2964\" type=\"checkbox\" name=\"vfb-field-2964[10]\" value=\"1\">Certified Case Manager Interventionist - Intern (CCMI-i)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-2964-11\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-2964\" type=\"checkbox\" name=\"vfb-field-2964[11]\" value=\"1\">Certified Case Manager Interventionist - Associate (CCMI-A)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-2964-12\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-2964\" type=\"checkbox\" name=\"vfb-field-2964[12]\" value=\"1\">Certified Case Manager Interventionist (CCMI)<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-2964-13\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-2964\" type=\"checkbox\" name=\"vfb-field-2964[13]\" value=\"1\">Certified Case Manager Interventionist - Masters Level (CCMI-M)<\/label><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-checkbox\" id=\"vfbField2965\"><label for=\"vfb-field-2965\" class=\"vfb-control-label\">Request for Credential Upgrade<\/label><div><span class=\"vfb-help-block\">You may request an upgrade of your current RAS or CCMI credentials at the same time that you submit this renewal. There is no additional fee to upgrade your RAS or CCMI Credentials to a higher level.\r\n\r\nPlease select the advanced credential(s) you are seeking:<\/span><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-2965-0\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-2965\" type=\"checkbox\" name=\"vfb-field-2965[0]\" value=\"1\">RAS II<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-2965-1\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-2965\" type=\"checkbox\" name=\"vfb-field-2965[1]\" value=\"1\">RAS III<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-2965-2\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-2965\" type=\"checkbox\" name=\"vfb-field-2965[2]\" value=\"1\">M-RAS<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-2965-3\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-2965\" type=\"checkbox\" name=\"vfb-field-2965[3]\" value=\"1\">CCMI-A<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-2965-4\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-2965\" type=\"checkbox\" name=\"vfb-field-2965[4]\" value=\"1\">CCMI<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-2965-5\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-2965\" type=\"checkbox\" name=\"vfb-field-2965[5]\" value=\"1\">CCMI-M<\/label><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-instructions\" id=\"vfbField2966\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2966\" class=\"vfb-control-label\">Credential upgrade qualifications<\/label><div class=\"\"><p class=\"p1\">RAS II &#8211; requires<\/p>\n<ul class=\"ul1\">\n<li class=\"li2\"><span class=\"s1\">AA Degree in healing arts or sciences and 3 years clinical experience; or<\/span><\/li>\n<li class=\"li2\"><span class=\"s1\">450 hours formal AOD education and 5 years clinical experience; or<br \/>\n<\/span><\/li>\n<li>Seven (7) years clinical experience (must have a minimum of 155 hours formal AOD education).<\/li>\n<\/ul>\n<p class=\"p1\">RAS III &#8211; requires<\/p>\n<ul class=\"ul1\">\n<li class=\"li2\"><span class=\"s1\">BA Degree in healing arts or sciences and 3 years clinical experience; or<br \/>\n<\/span><\/li>\n<li class=\"li2\"><span class=\"s1\">AA Degree in healing arts or sciences and 5 years clinical experience; or<\/span><span class=\"s1\"><br \/>\n<\/span><\/li>\n<li>Eight (8) years clinical experience (must have a minimum of 155 hours formal AOD education).<\/li>\n<\/ul>\n<p class=\"p1\">M-RAS &#8211; requires<\/p>\n<ul class=\"ul1\">\n<li class=\"li2\"><span class=\"s1\">MA or Doctorate Degree in healing arts or sciences and 3 years clinical experience; or<br \/>\n<\/span><\/li>\n<li class=\"li2\"><span class=\"s1\">BA Degree in healing arts or sciences and 5 years clinical experience; or<\/span><span class=\"s1\"><br \/>\n<\/span><\/li>\n<li>Ten (10) years clinical experience (must have a minimum of 155 hours formal AOD education).<\/li>\n<\/ul>\n<p class=\"p1\">CCMI-A &#8211; requires the CCMI i Credential, <span class=\"s2\">plus:<\/span><\/p>\n<ul class=\"ul2\">\n<li class=\"li2\"><span class=\"s1\">Completion of specified 5 Modules (at least 125 hours) CCMI training course; and,<br \/>\n<\/span><\/li>\n<li>Pass CCMI Credential exam administered online by Breining Institute.<\/li>\n<\/ul>\n<p class=\"p1\">CCMI<span class=\"s2\">:<\/span><\/p>\n<ul class=\"ul2\">\n<li>CCMI-Associate may apply for full CCMI Credential after completing 3,000 hours of supervised experience, over a minimum of two years, after registering as a CCMI-Intern.<\/li>\n<\/ul>\n<p class=\"p1\">CCMI-M &#8211; requires the CCMI Credential, <span class=\"s2\">plus any one of the following:<\/span><\/p>\n<ul class=\"ul2\">\n<li class=\"li2\"><span class=\"s1\">At least five (5) years health care professional clinical experience;<\/span><\/li>\n<li class=\"li2\"><span class=\"s1\">At least two (2) years health care professional clinical experience after having been awarded\u00a0the CCMI Credential; or<\/span><\/li>\n<li class=\"li2\"><span class=\"s1\">A Masters or Doctorate Degree in the healing arts.<\/span><\/li>\n<\/ul>\n<\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-file-upload\" id=\"vfbField2967\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2967\" class=\"vfb-control-label\">Credential upgrade file upload<\/label><div><span class=\"vfb-help-block\">If you are seeking to upgrade a current credential, please upload documentation of the qualifying formal education (such as a diploma or transcripts) and\/or clinical experience (such as letters from your employers) to verify your eligibility for the advanced credential. Please upload your documents here by selecting the \"Browse\" or \"Choose File\" button below and selecting the file(s) on your computer that you would like to submit. You may submit up to 3 documents.<\/span><input id=\"vfb-field-2967\" class=\"vfb-form-control vfb-file-input\" placeholder=\"\" data-max-file-count=\"3\" type=\"file\" name=\"vfb-field-2967\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-instructions\" id=\"vfbField2968\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2968\" class=\"vfb-control-label\">If you are unable to upload documents<\/label><div class=\"\"><p>If you are unable to upload the documents using this online form, you may send them to us by attaching them to an email, using the following:<\/p>\n<p>Email: College@Breining.edu<\/p>\n<\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><\/section><section class=\"vfb-page-section\"><h3 class=\"vfb-page-title\">CE Completion<\/h3><div class=\"vfb-col-12 vfb-fieldType-page-break\" id=\"vfbField2969\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-checkbox\" id=\"vfbField2970\"><label for=\"vfb-field-2970\" class=\"vfb-control-label\">Continuing Education (CE) Completion information: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">I attest that I have or will complete the required CE courses for the applicable certification(s) by my current renewal date.<\/span><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-2970-0\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-2970\" required=\"required\" type=\"checkbox\" name=\"vfb-field-2970[0]\" value=\"1\">I have completed a 30-hour (or 40-hour) Breining Institute CE Bundle which included topics to update existing knowledge and improve the skill sets of licensed and\/or certified healthcare professionals in substance abuse treatment and education settings.<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-2970-1\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-2970\" type=\"checkbox\" name=\"vfb-field-2970[1]\" value=\"1\">I have or will complete the required 30-hours of continuing education through other legitimate CE provider(s).<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-2970-2\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-2970\" type=\"checkbox\" name=\"vfb-field-2970[2]\" value=\"1\">I have or will complete the required 30-hour of continuing education through Breining Institute and other legitimate CE providers.<\/label><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-form-group vfb-col-12\"><div><div class=\"\">Optional Discount<\/div><\/div><\/div><div class=\"vfb-col-12 vfb-fieldType-heading\" id=\"vfbField2971\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-instructions\" id=\"vfbField2972\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2972\" class=\"vfb-control-label\">$50 discount if complete Breining 30-hour CE Bundle<\/label><div class=\"\"><p>If you have completed one of the Breining Institute 30-hour Continuing Education (CE) Bundles for this renewal (or previously completed a Breining Institute 40-hour CE Bundle), we will discount your Credential renewal fee by $50.<\/p>\n<p>Here are the eligible 30-hour and 40-hour Bundles:<\/p>\n<ul>\n<li>30-hour Telehealth Bundle<\/li>\n<li>30-hour International Bundle<\/li>\n<li>30-hour Veterans Bundle<\/li>\n<li>30-hour Nurses Bundle<\/li>\n<li>40-hour Global Bundle<\/li>\n<li>40-hour California Bundle<\/li>\n<\/ul>\n<p>All of the 30-hour Bundles are available on the Breining Institute website at this link: <a href=\"https:\/\/www.breining.edu\/index.php\/online-continuing-education-ce\/\">Online Continuing Education (CE)<\/a><\/p>\n<\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-file-upload\" id=\"vfbField2973\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2973\" class=\"vfb-control-label\">30-hour (or 40-hour) Bundle Completion Certificate upload<\/label><div><span class=\"vfb-help-block\">If you are requesting the discount, please upload a copy of the Completion Certificate that you received by email from Breining Institute when you completed the course. The certificate is a PDF document, and you may upload the certificate here by selecting the \"Browse\" or \"Choose File\" button below and selecting the PDF file on your computer that you would like to submit.<\/span><input id=\"vfb-field-2973\" class=\"vfb-form-control vfb-file-input\" placeholder=\"\" data-max-file-count=\"1\" data-allowed-file-extensions=\"pdf\" type=\"file\" name=\"vfb-field-2973\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-instructions\" id=\"vfbField2974\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2974\" class=\"vfb-control-label\">If you are unable to upload CE Completion Certificate<\/label><div class=\"\"><p>If you are unable to upload the CE Completion Certificate using this online form, you may send it to us by attaching it to an email, using the following:<\/p>\n<p>Email: College@Breining.edu<\/p>\n<\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><\/section><section class=\"vfb-page-section\"><h3 class=\"vfb-page-title\">Payment Info<\/h3><div class=\"vfb-col-12 vfb-fieldType-page-break\" id=\"vfbField2975\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-form-group vfb-col-12\"><div><div class=\"\">Payment Information<\/div><\/div><\/div><div class=\"vfb-col-12 vfb-fieldType-heading\" id=\"vfbField2976\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-form-group vfb-col-12\"><div><div class=\"\">Credit Card Charge Authorization<\/div><\/div><\/div><div class=\"vfb-col-12 vfb-fieldType-heading\" id=\"vfbField2977\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-radio\" id=\"vfbField2978\"><label for=\"vfb-field-2978\" class=\"vfb-control-label\">Select one of the Renewal Fee options below: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">You are authorizing Breining Institute to charge the renewal option amount you are selecting, below.<\/span><div class=\"vfb-radio\"><label><input id=\"vfb-field-2978-0\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-2978\" value=\"$275 - On-time Renewal\">$275 - On-time Renewal<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-2978-1\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-2978\" value=\"$375 - Late Renewal\">$375 - Late Renewal<\/label><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-radio\" id=\"vfbField2979\"><label for=\"vfb-field-2979\" class=\"vfb-control-label\">Optional Discount for CE Completion<\/label><div><span class=\"vfb-help-block\">If applicable, a $50 discount will be applied if you have completed a Breining Institute 30-hour or 40-hour) CE Bundle for this renewal, and have uploaded a copy of the Completion Certificate. <\/span><div class=\"vfb-radio\"><label><input id=\"vfb-field-2979-0\" class=\"\" placeholder=\"\" type=\"radio\" name=\"vfb-field-2979\" value=\"I am requesting a $50 discount for completing a Breining Institute 30-hour (or 40-hour) CE Bundle.\">I am requesting a $50 discount for completing a Breining Institute 30-hour (or 40-hour) CE Bundle.<\/label><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-instructions\" id=\"vfbField2980\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2980\" class=\"vfb-control-label\">Breining Institute is authorized to charge the above-selected amount to the following credit card:<\/label><div class=\"\"><p><span style=\"color: #ff0000;\">Please be careful to input all information carefully if you are authorizing a credit card charge now, in order to for us to promptly process your renewal.<\/span><\/p>\n<\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-radio\" id=\"vfbField2981\"><label for=\"vfb-field-2981\" class=\"vfb-control-label\">Credit Card: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><div class=\"vfb-radio\"><label><input id=\"vfb-field-2981-0\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-2981\" value=\"VISA\">VISA<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-2981-1\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-2981\" value=\"MasterCard\">MasterCard<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-2981-2\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-2981\" value=\"Discover\">Discover<\/label><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-number\" id=\"vfbField2982\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2982\" class=\"vfb-control-label\">Credit Card Number: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-2982\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"number\" name=\"vfb-field-2982\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField2983\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2983\" class=\"vfb-control-label\">Full Name on Credit Card: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-2983\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-2983\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField2984\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2984\" class=\"vfb-control-label\">Credit Card Expiration Date <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-2984\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-2984\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-instructions\" id=\"vfbField2985\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2985\" class=\"vfb-control-label\">ATTESTATION<\/label><div class=\"\"><p>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, minus the CE discount if applicable, to the credit card indicated. 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.<\/p>\n<\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-signature\" id=\"vfbField2986\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2986\" class=\"vfb-control-label\">Signature<\/label><div><span class=\"vfb-help-block\">Please carefully use this space to sign your name, which must match the signature we have on record in your credential file.<\/span><input id=\"vfb-field-2986\" class=\"vfb-form-control vfb-signature-input\" placeholder=\"\" type=\"hidden\" name=\"vfb-field-2986\" value=\"\"><div class=\"vfb-signature\"><\/div><div class=\"vfb-signature-buttons\"><a href=\"#\" class=\"btn btn-primary\">Reset Signature<\/a><\/div><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-captcha\" id=\"vfbField2987\"><div class=\"vfb-form-group\"><label for=\"vfb-field-2987\" class=\"vfb-control-label\">Captcha <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><div class=\"g-recaptcha\" data-sitekey=\"6LdWgN0UAAAAAM_hb1SqmzT2DP4J1X289K2epOVA\"><\/div><input type=\"hidden\" name=\"_vfb_recaptcha_enabled\" value=\"1\" id=\"\"><div class=\"vfb-has-error\" id=\"vfb-recaptcha-error\"><span class=\"vfb-help-block\">reCAPTCHA is required.<\/span><\/div><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-submit\" id=\"vfbField2988\"><button id=\"vfb-field-2988\" class=\" btn btn-primary\" placeholder=\"\" type=\"submit\" name=\"_vfb-submit\">Submit<\/button><\/div><div class=\"vfb-clearfix\"><\/div><\/section><\/form>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":10,"menu_order":0,"comment_status":"open","ping_status":"open","template":"","meta":{"footnotes":""},"class_list":["post-1323","page","type-page","status-publish","czr-hentry"],"_links":{"self":[{"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/pages\/1323","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/comments?post=1323"}],"version-history":[{"count":30,"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/pages\/1323\/revisions"}],"predecessor-version":[{"id":33165,"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/pages\/1323\/revisions\/33165"}],"up":[{"embeddable":true,"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/pages\/10"}],"wp:attachment":[{"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/media?parent=1323"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}