Basic Training Registration Form Name First Last Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email PhoneYears of education completed?(12 = GED or high school graduate, 16 = Bachelor’s degree or equivalent, 18 = master’s degree) What is the highest degree you currently hold? Have you completed certificates or degree’s directly related to drug or alcohol counseling (e.g., DARC)? Yes No If yes, please describe: Are you licensed to practice in a state? Yes No If you are licensed, what is your official title? How many months or years have you worked in your capacity as a drug or alcohol clinician? What are the main reasons you are accessing the basic contingency management training offered on this website?Comments:PhoneThis field is for validation purposes and should be left unchanged.