{"id":1756,"date":"2016-01-20T10:45:03","date_gmt":"2016-01-20T18:45:03","guid":{"rendered":"http:\/\/www.breining.edu\/?page_id=1756"},"modified":"2022-03-06T10:51:32","modified_gmt":"2022-03-06T18:51:32","slug":"addiction-counselor-exam-ace-request","status":"publish","type":"page","link":"https:\/\/www.breining.edu\/index.php\/professional-certification\/addiction-counselor-exam-ace-request\/","title":{"rendered":"Addiction Counselor Exam (ACE) Request"},"content":{"rendered":"<ul>\n<li>Please fill out this form completely. Incomplete forms will delay processing.<\/li>\n<li>We need a current photo to make this application complete. If you are unable to upload a current photo with this form (below), you may submit it to us by postal mail or email.<\/li>\n<li>The $175 exam fee is non-refundable, and does not include retake exams (if needed).<\/li>\n<li>Exam must be scheduled and taken within one month, or exam fee will be forfeited.<\/li>\n<li>If the ACE Exam candidate does not take the exam at the scheduled exam time without at least twenty-four (24) hours advanced rescheduling of the exam, the exam fee will not be refunded, and the candidate will forfeit the exam fee, and will need to submit a new exam request and exam fee to take the exam<\/li>\n<\/ul>\n<h3><span style=\"color: #800000;\"><strong>Questions?<\/strong><\/span><\/h3>\n<p>Please call Breining Institute at 916-987-2007, or contact us by email by selecting this link: <a href=\"http:\/\/www.breining.edu\/index.php\/contact-us\/email-us\/\" target=\"_blank\" rel=\"noopener\">Email<\/a><\/p>\n<form method=\"post\" enctype=\"multipart\/form-data\" id=\"vfbp-form-11\" 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-11\" value=\"1775232600\" id=\"\"><input type=\"hidden\" name=\"_vfb-form-id\" value=\"11\" id=\"\"><div class=\"vfb-form-group vfb-col-12\"><div><div class=\"\">Section 1: ACE Exam Candidate Information<\/div><\/div><\/div><div class=\"vfb-col-12 vfb-fieldType-heading\" id=\"vfbField249\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField256\"><div class=\"vfb-form-group\"><label for=\"vfb-field-256\" class=\"vfb-control-label\">Full Name: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-256\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-256\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-address\" id=\"vfbField265\"><div class=\"vfb-form-group\"><label for=\"vfb-field-265\" class=\"vfb-control-label\">Address <span class=\"vfb-required-asterisk\">*<\/span><\/label><div class=\"vfb-address-block\" id=\"vfb-field-265\"><div class=\"vfb-form-group\" style=\"\"><input id=\"vfb-field-265-address-1\" class=\"vfb-form-control vfb-addresspart-address-1\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-265[address-1]\"><\/div><div class=\"vfb-form-group\" style=\"\"><label for=\"vfb-field-265-address-2\" class=\"vfb-address-label\">Apt, suite, etc.<\/label><input id=\"vfb-field-265-address-2\" class=\"vfb-form-control vfb-addresspart-address-2\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-265[address-2]\"><\/div><div class=\"vfb-form-group\" style=\"\"><label for=\"vfb-field-265-country\" class=\"vfb-address-label\">Country<\/label><select id=\"vfb-field-265-country\" class=\"vfb-form-control vfb-addresspart-country\" placeholder=\"\" required=\"required\" name=\"vfb-field-265[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-265-city\" class=\"vfb-address-label\">City<\/label><input id=\"vfb-field-265-city\" class=\"vfb-form-control vfb-addresspart-city\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-265[city]\"><\/div><div class=\"vfb-form-group\" style=\"\"><label for=\"vfb-field-265-province\" class=\"vfb-address-label\">State<\/label><select id=\"vfb-field-265-province\" class=\"vfb-form-control vfb-addresspart-province\" placeholder=\"\" required=\"required\" name=\"vfb-field-265[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-265-zip\" class=\"vfb-address-label\">Zip code<\/label><input id=\"vfb-field-265-zip\" class=\"vfb-form-control vfb-addresspart-zip\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-265[zip]\"><\/div><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField266\"><div class=\"vfb-form-group\"><label for=\"vfb-field-266\" class=\"vfb-control-label\">Date of Birth <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-266\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-266\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-radio\" id=\"vfbField267\"><label for=\"vfb-field-267\" class=\"vfb-control-label\">Gender <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><div class=\"vfb-radio\"><label><input id=\"vfb-field-267-0\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-267\" value=\"Male\">Male<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-267-1\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-267\" value=\"Female\">Female<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-267-2\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-267\" value=\"Other\">Other<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-267-3\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-267\" value=\"Prefer not to disclose\">Prefer not to disclose<\/label><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField269\"><div class=\"vfb-form-group\"><label for=\"vfb-field-269\" class=\"vfb-control-label\">Social Security Number: Last 4 digits only <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><span class=\"vfb-help-block\">Please only include the last 4 digits (numbers) of your Social Security Number. If you do not have a Social Security Number, please include the last four digits of another government identification card, and identify which government identification you are using.<\/span><input id=\"vfb-field-269\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-269\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-email\" id=\"vfbField259\"><div class=\"vfb-form-group\"><label for=\"vfb-field-259\" class=\"vfb-control-label\">Email Address: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-259\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"email\" name=\"vfb-field-259\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-email\" id=\"vfbField260\"><div class=\"vfb-form-group\"><label for=\"vfb-field-260\" class=\"vfb-control-label\">Confirm Email Address: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-260\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"email\" name=\"vfb-field-260\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-phone\" id=\"vfbField264\"><div class=\"vfb-form-group\"><label for=\"vfb-field-264\" class=\"vfb-control-label\">Primary Phone Number <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-264\" class=\"vfb-form-control vfb-intl-phone\" placeholder=\"\" required=\"required\" type=\"tel\" name=\"vfb-field-264\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-file-upload\" id=\"vfbField271\"><div class=\"vfb-form-group\"><label for=\"vfb-field-271\" class=\"vfb-control-label\">Current Photo<\/label><div><span class=\"vfb-help-block\">We must have a current photo of the ACE Exam candidate, which will be used to verify identification of candidate at the time of the exam. You may upload it as a document with any one of the following extensions: JPG, JPEG, PNG or GIF. If you are unable to upload a photo here, please send to Breining Institute by postal mail or email attachment.<\/span><input id=\"vfb-field-271\" class=\"vfb-form-control vfb-file-input\" placeholder=\"\" type=\"file\" name=\"vfb-field-271\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-form-group vfb-col-12\"><div><div class=\"\">Section 2: Certification or License<\/div><\/div><\/div><div class=\"vfb-col-12 vfb-fieldType-heading\" id=\"vfbField246\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-checkbox\" id=\"vfbField247\"><label for=\"vfb-field-247\" class=\"vfb-control-label\">Identify which certification or license you are testing to earn, and from which agency <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-247-0\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-247\" required=\"required\" type=\"checkbox\" name=\"vfb-field-247[0]\" value=\"1\">Registered Addiction Specialist (RAS): Breining Institute<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-247-1\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-247\" type=\"checkbox\" name=\"vfb-field-247[1]\" value=\"1\">RAS - Level II (RAS II): Breining Institute<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-247-2\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-247\" type=\"checkbox\" name=\"vfb-field-247[2]\" value=\"1\">RAS - Level III (RAS III): Breining Institute<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-247-3\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-247\" type=\"checkbox\" name=\"vfb-field-247[3]\" value=\"1\">Masters Level - RAS (M-RAS): Breining Institute<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-247-4\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-247\" type=\"checkbox\" name=\"vfb-field-247[4]\" value=\"1\">Other:<\/label><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField270\"><div class=\"vfb-form-group\"><label for=\"vfb-field-270\" class=\"vfb-control-label\">If you selected Other, identify the certification and\/or license and agency, here:<\/label><div><input id=\"vfb-field-270\" class=\"vfb-form-control\" placeholder=\"\" type=\"text\" name=\"vfb-field-270\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-form-group vfb-col-12\"><div><div class=\"\">Section 3. Formal Education<\/div><\/div><\/div><div class=\"vfb-col-12 vfb-fieldType-heading\" id=\"vfbField948\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-checkbox\" id=\"vfbField949\"><label for=\"vfb-field-949\" class=\"vfb-control-label\">Have you started or completed the formal education required to earn the certificate or license identified in Section 2, above? <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-949-0\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-949\" required=\"required\" type=\"checkbox\" name=\"vfb-field-949[0]\" value=\"1\">Yes<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-949-1\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-949\" type=\"checkbox\" name=\"vfb-field-949[1]\" value=\"1\">No<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-949-2\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-949\" type=\"checkbox\" name=\"vfb-field-949[2]\" value=\"1\">Not applicable<\/label><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField950\"><div class=\"vfb-form-group\"><label for=\"vfb-field-950\" class=\"vfb-control-label\">If your answer to the above is YES, please identify the course or degree that you have started or completed, and the name of the institution:<\/label><div><input id=\"vfb-field-950\" class=\"vfb-form-control\" placeholder=\"\" type=\"text\" name=\"vfb-field-950\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-form-group vfb-col-12\"><div><div class=\"\">Section 4: Other licenses or certifications<\/div><\/div><\/div><div class=\"vfb-col-12 vfb-fieldType-heading\" id=\"vfbField261\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-textarea\" id=\"vfbField262\"><div class=\"vfb-form-group\"><label for=\"vfb-field-262\" class=\"vfb-control-label\">List any other licenses or certifications you hold in the healthcare field.<\/label><div><span class=\"vfb-help-block\">This will assist us in awarding the highest level RAS Credential possible. Please include a copy of your license\/certificate. This includes Registered Nurse (RN); Marriage and Family Therapist (MFT); Licensed Clinical Social Worker (LCSW); Medical Doctor (MD); and other similar licenses and\/or certifications.<\/span><textarea id=\"vfb-field-262\" class=\"vfb-form-control\" placeholder=\"\" rows=\"10\" name=\"vfb-field-262\" cols=\"50\"><\/textarea><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-file-upload\" id=\"vfbField272\"><div class=\"vfb-form-group\"><label for=\"vfb-field-272\" class=\"vfb-control-label\">License or Certificate Upload<\/label><div><span class=\"vfb-help-block\">If you identified a certificate or license, above, please upload a copy of it here. You may upload it as a document with any one of the following extensions: JPG, JPEG, PNG, GIF, DOC or DOCX.\r\nIf you are unable to upload the certificate or license here, please send it to us by postal mail or email.<\/span><input id=\"vfb-field-272\" class=\"vfb-form-control vfb-file-input\" placeholder=\"\" type=\"file\" name=\"vfb-field-272\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-form-group vfb-col-12\"><div><div class=\"\">Section 5: Credit Card and Payment Information<\/div><\/div><\/div><div class=\"vfb-col-12 vfb-fieldType-heading\" id=\"vfbField252\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-instructions\" id=\"vfbField253\"><div class=\"vfb-form-group\"><label for=\"vfb-field-253\" class=\"vfb-control-label\">You give permission to and authorize Breining Institute to charge one hundred seventy-five dollars ($175.00) to the following credit card:<\/label><div class=\"\"><ul>\n<li>Includes examination, only.<\/li>\n<li>Does not include retake exams (if needed).<\/li>\n<li>Exam fee is nonrefundable.<\/li>\n<li>Exam must be scheduled and taken within one month of submitting this exam request.<\/li>\n<li>If the ACE Exam candidate does not take the exam at the scheduled exam time without at least twenty-four (24) hours advanced rescheduling of the exam, the exam fee will not be refunded, and the candidate will forfeit the exam fee, and will need to submit a new exam request and exam fee to take the exam.<\/li>\n<\/ul>\n<\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-radio\" id=\"vfbField251\"><label for=\"vfb-field-251\" class=\"vfb-control-label\">Credit Card:<\/label><div><div class=\"vfb-radio\"><label><input id=\"vfb-field-251-0\" class=\"\" placeholder=\"\" type=\"radio\" name=\"vfb-field-251\" value=\"VISA\">VISA<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-251-1\" class=\"\" placeholder=\"\" type=\"radio\" name=\"vfb-field-251\" value=\"MasterCard\">MasterCard<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-251-2\" class=\"\" placeholder=\"\" type=\"radio\" name=\"vfb-field-251\" value=\"Discover\">Discover<\/label><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-number\" id=\"vfbField248\"><div class=\"vfb-form-group\"><label for=\"vfb-field-248\" class=\"vfb-control-label\">Credit Card Number:<\/label><div><input id=\"vfb-field-248\" class=\"vfb-form-control\" placeholder=\"\" type=\"number\" name=\"vfb-field-248\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField258\"><div class=\"vfb-form-group\"><label for=\"vfb-field-258\" class=\"vfb-control-label\">Full Name on Credit Card:<\/label><div><input id=\"vfb-field-258\" class=\"vfb-form-control\" placeholder=\"\" type=\"text\" name=\"vfb-field-258\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField263\"><div class=\"vfb-form-group\"><label for=\"vfb-field-263\" class=\"vfb-control-label\">Credit Card Expiration Date<\/label><div><input id=\"vfb-field-263\" class=\"vfb-form-control\" placeholder=\"\" type=\"text\" name=\"vfb-field-263\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-captcha\" id=\"vfbField751\"><div class=\"vfb-form-group\"><label for=\"vfb-field-751\" 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=\"vfbField255\"><button id=\"vfb-field-255\" class=\" btn btn-primary\" placeholder=\"\" type=\"submit\" name=\"_vfb-submit\">Submit<\/button><\/div><div class=\"vfb-clearfix\"><\/div><\/form>\n<hr \/>\n<p>REGISTERED SERVICE MARKS<\/p>\n<p><span class=\"s1\">&#8220;Addiction Counselor Exam&#8221; and &#8220;ACE&#8221; are registered marks of Breining Institute: Service Mark Reg. Nos. 68184, 304796, Class Number 41<\/span><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Please fill out this form completely. Incomplete forms will delay processing. We need a current photo to make this application complete. If you are unable to upload a current photo with this form (below), you may submit it to us by postal mail or email. The $175 exam fee is non-refundable, and does not include [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":10,"menu_order":0,"comment_status":"open","ping_status":"open","template":"","meta":{"footnotes":""},"class_list":["post-1756","page","type-page","status-publish","czr-hentry"],"_links":{"self":[{"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/pages\/1756","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=1756"}],"version-history":[{"count":11,"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/pages\/1756\/revisions"}],"predecessor-version":[{"id":21797,"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/pages\/1756\/revisions\/21797"}],"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=1756"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}