Certification Commission Policy and Procedure Manual
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 Withdrawn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idate Status Withdrawn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 Withdrawn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idate Status Withdrawn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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