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#18-004710-0001
Supplemental Questionnaire

Last Name
First Name

 

***Please note that your answers on the supplemental questionnaire must correspond to the information provided on your application to receive credit.***


1.

Do you possess a Licensed Clinical Alcohol and Drug Counselor (LCADC)?

Yes No
 

If yes, please describe your supervisory experience.  Include in your response the employer name(s), job title(s), dates of employment, and titles of those you supervised.  If you do not possess this experience, enter N/A.


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