APPLICATION FOR POST-APPROVAL OF CONTINUING EDUCATION
(If the activity you completed did not have prior approval from CRCC, you must complete a SEPARATE form for each continuing education activity for which you seek credit, a copy of proof of attendance, and appropriate fee. To submit future requests, make copies of this form BEFORE completing it.)

Check one: __ CRC __ CCRC __ CRC-MAC __ CRC-CS __ CRC-MAC-CS

Customer Number________________________
______________________________
Last Name		 ______________________________
First Name		 ______________________________
Middle Name
______________________________
Street Address		 ______________________________
City and State/Province		 ______________________________
Zip Code / Postal Code
______________________________
Daytime Telephne Number (with area code)		 ______________________________
Facsimile Number (with area code
________________________________________________________________
Program Title		 ______________________________
Program Location (city and state)
________________________________________________________________
Sponsoring Organization		 ______________________________
Program Dates
________________________________________________________________
Program Instructors		 ______________________________
Clock Hours Requested
Check the title that most accurately describes the activity that you completed.
1- Multi-day Conference 3- Home Study 5- Internet
2- Seminar/Workshop 4- College or University Courses
Complete this section if your activity falls within one or more of the domain focus areas.
1. Indicate the domain focus area that describes the content of your continuing education activity.
01 - Vocational Consultation and Employer Services
02 - Job Development and Placement Services
03 - Career Counseling and Assessment Techniques
04 - Mental Health Counseling
05 - Group and Family Counseling
06 - Individual Counseling
07 - Psychosocial and Cultural Issues in Counseling
08 - Foundations and Professional Issues
09 - Rehabilitation Services and Resources
10 - Case and Caseload Management
11 - Healthcare and Disability Systems
12 - Medical, Functional and Environmental Implications of Disabilities
13 - Ethical Standards
14 - Addictions Counseling
15 - Clinical Supervision
16 - Professional Development

2.
Describe how your continuing education activity relates to your professional development. Use a separate piece of paper if necessary.
________________________________________________________________________

3.
Attach all required documentation and the non-refundable processing fee.
Complete this section if your activity falls within one or more of the professional development areas.
1.
Describe how your continuing education activity relates to your professional development. Use a separate piece of paper if necessary.
________________________________________________________________________
2. Attach all required documentation and the non-refundable processing fee.
________________________________________________________________________
The fee for one request is $10. A fee of $35 is charged if you are submitting requests for approval of four or more programs completed in the same calendar year (January 1 through December 31). Payment may be made to CRCC by check or money order.

All fees are non-refundable.
Enclosed is the $10 fee. Enclosed is the $35 fee. $ _______ is enclosed.

Signature ________________________________________
Date ___________________

Commission on Rehabilitation Counselor Certification. (2006).
Application for Post-Approval of Continuing Education.
Retrieved [date] from, http://www.crccertification.com/pages/15ce.html