(Please Check Where Requested as Indication You Have Read and Understand Each Section)
I hereby attest that all the information given herein is true and complete to the best
of my knowledge and belief. I understand that falsification of any portion of this application will
result in my being denied certification, or revocation of same, upon discovery.
I have read, understand, and agree to act in accordance with the ADACBGA Code
of Ethics, NAADAC Code of Ethics, and any other codes of ethical conduct recognized by my
profession and in compliance with any and all codes of professional conduct in effect in the State
I acknowledge the right of ADACBGA to verify the information in this application
or to seek further information from employers, schools or persons mentioned herein.
) I further understand that that it is my responsibility to maintain my certification
by renewing prior to my expiration date. I understand that it is an ethical violation to provide
services if my certification has expired. I understand that I must keep my contact information upto-date with the ADACBGA at all times, as failure to retrieve a certified letter or respond to an
email shall not be a valid reason to failure to respond to official correspondence from the
ADACBGA and/or the Ethics Committee.
I agree to have my current valid certificate from ADACBGA on display or easily
accessible if I am providing treatment to service recipients.
I will hold ADACBGA, its Board members, officers, agents, and staff free from
any civil liability for damages or complaints by reason of any action that is within the scope and
arising out of the performance of their duties which they, or any of them, may take in connection
with this application, the attendant examination, the grades with respect to any examination, and/or
failure of the Board to bestow upon me certification as an alcohol and drug abuse counselor.
I further understand that ADACBGA will post on our website and provide to
IC&RC my contact information for their data base, along with my certification number, level,
expiration date and original certification date.