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Certification Commission Policy and Procedure Manual

Certification Commission Policy and Procedure Manual

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APPENDIX 3 D cont’d<br />

APPLICANT:<br />

Page 3<br />

DATE:<br />

Notations or Recommendations (Write out notations or recommendations, if any): *<br />

* Note: Applicants who are granted Associate Supervisor status might receive one or two<br />

specific notations that are concretely related to the applicant’s process of becoming<br />

certified as a ACPE Supervisor. Notations may only be removed by the <strong>Certification</strong><br />

<strong>Commission</strong> - not by regional <strong>Certification</strong> Committees which grant extension of Associate<br />

Supervisor status. Notations must be addressed adequately by the Associate Supervisor to<br />

be certified as ACPE Supervisor.<br />

SUBCOMMITTEE MEMBERS:<br />

(Please Print)<br />

_____________________________________<br />

Presenter<br />

_____________________________________<br />

Sub-committee chair<br />

_____________________________________<br />

_____________________________<br />

_____________________________<br />

_____________________________________<br />

<strong>Commission</strong> Chair<br />

23

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