© 2014 Breining Institute – www.breining.edu (1412060847) ACE EXAM REQUEST 1

ADDICTION COUNSELOR EXAM (ACE) Request

Breining Institute • 8894 Greenback Lane • Orangevale, California USA 95662-4019 • Telephone (916) 987-2007

Please type or print all of your information clearly. Must include a recent photograph of candidate.

SECTION 1: ACE Exam Candidate Information Name ____________________________________________________________________________________________ Address ____________________________________________________________________________________________ City ____________________________________________________________________________________________ State _________________________________________ ZIP Code ______________________________ E-mail _________________________________________ Phone ______________________________ SECTION 2: Identify which certification or license you are testing to earn, and from which agency ☐ Registered Addiction Specialist (RAS) – Breining Institute ☐ RAS – Level II (RAS II) – Breining Institute ☐ RAS – Level III (RAS III) – Breining Institute ☐ Masters Level – RAS (M-RAS) – Breining Institute ☐ Other: ____________________________________________________________________________________________ SECTION 3: List any other licenses or certifications you hold in the healthcare field This will assist us in awarding the highest level RAS Credential possible. Please include a copy of your license/certificate. ☐ Registered Nurse (RN) ☐ Marriage and Family Therapist (MFT) ☐ Licensed Clinical Social Worker (LCSW) ☐ Medical Doctor (MD) ☐ Other: ____________________________________________________________________________________________ ☐ Other: ____________________________________________________________________________________________ SECTION 4: Examination Fee Examination Fee. Includes the examination, only. Nonrefundable. ....................................................................................... $175.00 • Exam must be scheduled and taken within three months of submitting this exam request. If the ACE Exam candidate does

not show up for the scheduled exam time without advanced rescheduling of the exam, the exam fee will not be refunded. Checks for ACE Exam should be made payable to “Breining Institute.” If paying by VISA, MasterCard or Discover, you may fax, e-mail or send by postal mail this form to: • FAX number: 916-987-8823 • E-mail: Certification@Breining.edu • Mailing address: Breining Institute, 8894 Greenback Lane, Orangevale, California USA 95662-4019

• Credit card number: _______________________________________________________________

• Full name on credit card: _______________________________________________________________

• Credit card expiration date: _______________________________________________________________ SECTION 5: Directions for submitting ACE Exam Request Please send to Breining Institute this form and payment by fax, e-mail or postal mail, and include recent photograph and documentation (if applicable) of any other license or certification in the health care field that you currently hold.

Questions? Please call Breining Institute at 916-987-2007