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Certification Commission Policy and Procedure Manual

Certification Commission Policy and Procedure Manual

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ASSOCIATION FOR CLINICAL PASTORAL EDUCATION, INC.<br />

1549 Clairmont Road, Suite 103<br />

Decatur, Georgia 30033<br />

REGIONAL CERTIFICATION REPORT FORM 4<br />

INSTRUCTIONS:<br />

Send original Form 4 with copy of Regional Docket to the ACPE office.<br />

Send copy of Form 4 to Regional Director. SIGNATURE REQUIRED!<br />

Region Reporting: ______________________<br />

Date: ______________<br />

Date of Action: ____________________<br />

Type of Action: New Supervisory C<strong>and</strong>idate <strong>Certification</strong> Withdrawn<br />

Supervisory C<strong>and</strong>idate Status Withdrawn<br />

Extension: Granted ____ Denied____<br />

Active to Inactive Status<br />

Inactive to Active Status<br />

Associate Supervisory C<strong>and</strong>idate New CPE Supervisor<br />

Name: _________________________________________________________________________________<br />

Center Name:<br />

Mailing Address: _________________________________________________________________________<br />

City & State: _________________________________________ Zip Code: ____________________<br />

Date of Action: ____________________<br />

Type of Action: New Supervisory C<strong>and</strong>idate <strong>Certification</strong> Withdrawn<br />

Supervisory C<strong>and</strong>idate Status Withdrawn<br />

Extension: Granted____ Denied____<br />

Active to Inactive Status<br />

Inactive to Active Status<br />

Associate Supervisory C<strong>and</strong>idate New CPE Supervisor<br />

Name: ___________________________________________________________________________________<br />

Center Name:<br />

Mailing Address: ___________________________________________________________________________<br />

City & State: __________________________________________ Zip Code: _______________________<br />

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