{"id":19777,"date":"2021-08-04T10:02:44","date_gmt":"2021-08-04T17:02:44","guid":{"rendered":"https:\/\/www.breining.edu\/?page_id=19777"},"modified":"2021-08-04T10:05:10","modified_gmt":"2021-08-04T17:05:10","slug":"credential-application-and-or-exam-fee-payments","status":"publish","type":"page","link":"https:\/\/www.breining.edu\/index.php\/credential-application-and-or-exam-fee-payments\/","title":{"rendered":"Credential Application and\/or Exam Fee Payments"},"content":{"rendered":"<form method=\"post\" enctype=\"multipart\/form-data\" id=\"vfbp-form-64\" 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-64\" value=\"1782290888\" id=\"\"><input type=\"hidden\" name=\"_vfb-form-id\" value=\"64\" id=\"\"><section class=\"vfb-page-section\"><h3 class=\"vfb-page-title\">Instructions<\/h3><div class=\"vfb-col-12 vfb-fieldType-page-break\" id=\"vfbField1806\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-instructions\" id=\"vfbField1807\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1807\" class=\"vfb-control-label\">Credential Application Payment Form<\/label><div class=\"\"><h4><a href=\"https:\/\/www.breining.edu\/wp-content\/uploads\/2021\/08\/SpecCred2021.jpeg\"><img loading=\"lazy\" decoding=\"async\" class=\"alignnone size-full wp-image-19773\" src=\"https:\/\/www.breining.edu\/wp-content\/uploads\/2021\/08\/SpecCred2021.jpeg\" alt=\"\" width=\"1200\" height=\"315\" srcset=\"https:\/\/www.breining.edu\/wp-content\/uploads\/2021\/08\/SpecCred2021.jpeg 1200w, https:\/\/www.breining.edu\/wp-content\/uploads\/2021\/08\/SpecCred2021-300x79.jpeg 300w, https:\/\/www.breining.edu\/wp-content\/uploads\/2021\/08\/SpecCred2021-1024x269.jpeg 1024w, https:\/\/www.breining.edu\/wp-content\/uploads\/2021\/08\/SpecCred2021-768x202.jpeg 768w\" sizes=\"auto, (max-width: 1200px) 100vw, 1200px\" \/><\/a><\/h4>\n<h4><span style=\"color: #ff0000;\">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<p>After you have submitted your Credential Application, you may use this online form to provide payment information to Breining Institute.<\/p>\n<p>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<\/p>\n<hr noshade=\"noshade\" size=\"5\" \/>\n<h4><span style=\"color: #800000;\">Payment Options:<\/span><\/h4>\n<p>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 &#8220;Payment Information&#8221; section of this form.<\/p>\n<ul>\n<li><strong>Addiction Counselor Exam (ACE): $175<\/strong><\/li>\n<li><strong>Private-practice \/ Clinical Supervisor (PCS) Exam: $175<\/strong><\/li>\n<li><strong>Certified Case Manager Interventionist (CCMI) Application Fee: $75<\/strong><\/li>\n<li><strong>Certified Case Manager Interventionist (CCMI) Exam Fee: $175<\/strong><\/li>\n<\/ul>\n<hr noshade=\"noshade\" size=\"5\" \/>\n<p>IMPORTANT NOTICE: Applications or exam requests that require payment will not be processed until payment is confirmed.<\/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=\"vfbField1808\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-form-group vfb-col-12\"><div><div class=\"\">Applicant Information<\/div><\/div><\/div><div class=\"vfb-col-12 vfb-fieldType-heading\" id=\"vfbField1809\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField1810\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1810\" class=\"vfb-control-label\">Full Name: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-1810\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-1810\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField1811\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1811\" class=\"vfb-control-label\">Address: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-1811\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-1811\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField1812\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1812\" class=\"vfb-control-label\">City:<\/label><div><input id=\"vfb-field-1812\" class=\"vfb-form-control\" placeholder=\"\" type=\"text\" name=\"vfb-field-1812\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField1813\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1813\" class=\"vfb-control-label\">State \/ Province: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-1813\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-1813\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField1814\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1814\" class=\"vfb-control-label\">ZIP Code or Country Code: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-1814\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-1814\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-select\" id=\"vfbField1815\"><label for=\"vfb-field-1815\" class=\"vfb-control-label\">Country: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><div class=\"vfb-form-group\"><select id=\"vfb-field-1815\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" name=\"vfb-field-1815\"><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=\"vfbField1816\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1816\" class=\"vfb-control-label\">Country (if not the United States):<\/label><div><input id=\"vfb-field-1816\" class=\"vfb-form-control\" placeholder=\"\" type=\"text\" name=\"vfb-field-1816\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-email\" id=\"vfbField1817\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1817\" class=\"vfb-control-label\">Email Address: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-1817\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"email\" name=\"vfb-field-1817\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-email\" id=\"vfbField1818\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1818\" 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-1818\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" data-vfb-equalto=\"#vfb-field-1817\" type=\"email\" name=\"vfb-field-1818\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-phone\" id=\"vfbField1819\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1819\" class=\"vfb-control-label\">Primary Phone Number <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-1819\" class=\"vfb-form-control vfb-intl-phone\" placeholder=\"\" required=\"required\" type=\"tel\" name=\"vfb-field-1819\" value=\"\"><\/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=\"vfbField1832\"><\/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=\"vfbField1833\"><\/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=\"vfbField1834\"><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-instructions\" id=\"vfbField1837\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1837\" class=\"vfb-control-label\">Breining Institute is authorized to charge the above-selected amount(s) to the following credit card:<\/label><div class=\"\"><p><span style=\"color: #ff0000;\">Please be careful to input all information carefully, in order to for us to promptly process your payment.<\/span><\/p>\n<p><span style=\"color: #ff0000;\">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.<\/span><\/p>\n<p><span style=\"color: #ff0000;\">Please double check to ensure you have selected only those items for which you wish to be charged.<\/span><\/p>\n<\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-checkbox\" id=\"vfbField1846\"><label for=\"vfb-field-1846\" class=\"vfb-control-label\">Select the charges you wish to make below: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1846-0\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1846\" required=\"required\" type=\"checkbox\" name=\"vfb-field-1846[0]\" value=\"1\">Addiction Counselor Exam (ACE): $175<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1846-1\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1846\" type=\"checkbox\" name=\"vfb-field-1846[1]\" value=\"1\">Private-practice \/ Clinical Supervisor (PCS) Exam: $175<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1846-2\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1846\" type=\"checkbox\" name=\"vfb-field-1846[2]\" value=\"1\">Certified Case Manager Interventionist (CCMI) Application Fee: $75<\/label><\/div><div class=\"vfb-checkbox\"><label><input id=\"vfb-field-1846-3\" class=\"\" placeholder=\"\" data-vfb-multiple=\"vfb-field-1846\" type=\"checkbox\" name=\"vfb-field-1846[3]\" value=\"1\">Certified Case Manager Interventionist (CCMI) Exam Fee: $175<\/label><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-radio\" id=\"vfbField1838\"><label for=\"vfb-field-1838\" class=\"vfb-control-label\">Credit Card: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><div class=\"vfb-radio\"><label><input id=\"vfb-field-1838-0\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-1838\" value=\"VISA\">VISA<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-1838-1\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-1838\" value=\"MasterCard\">MasterCard<\/label><\/div><div class=\"vfb-radio\"><label><input id=\"vfb-field-1838-2\" class=\"\" placeholder=\"\" required=\"required\" type=\"radio\" name=\"vfb-field-1838\" value=\"Discover\">Discover<\/label><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-number\" id=\"vfbField1839\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1839\" class=\"vfb-control-label\">Credit Card Number: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-1839\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"number\" name=\"vfb-field-1839\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField1841\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1841\" class=\"vfb-control-label\">Credit Card Expiration Date <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-1841\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-1841\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-text\" id=\"vfbField1840\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1840\" class=\"vfb-control-label\">Full Name on Credit Card: <span class=\"vfb-required-asterisk\">*<\/span><\/label><div><input id=\"vfb-field-1840\" class=\"vfb-form-control\" placeholder=\"\" required=\"required\" type=\"text\" name=\"vfb-field-1840\" value=\"\"><\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-instructions\" id=\"vfbField1842\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1842\" 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(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.<\/p>\n<\/div><\/div><\/div><div class=\"vfb-clearfix\"><\/div><div class=\"vfb-col-12 vfb-fieldType-signature\" id=\"vfbField1843\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1843\" 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-1843\" class=\"vfb-form-control vfb-signature-input\" placeholder=\"\" type=\"hidden\" name=\"vfb-field-1843\" 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=\"vfbField1844\"><div class=\"vfb-form-group\"><label for=\"vfb-field-1844\" 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=\"vfbField1845\"><button id=\"vfb-field-1845\" 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":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-19777","page","type-page","status-publish","czr-hentry"],"_links":{"self":[{"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/pages\/19777","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=19777"}],"version-history":[{"count":1,"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/pages\/19777\/revisions"}],"predecessor-version":[{"id":19778,"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/pages\/19777\/revisions\/19778"}],"wp:attachment":[{"href":"https:\/\/www.breining.edu\/index.php\/wp-json\/wp\/v2\/media?parent=19777"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}