Form Pds-37 - Casac And Cpp/cps Gambling Specialty Designation Request Form Page 4

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New York State Office of Alcoholism and Substance Abuse Services

CASAC and CPP/CPS Gambling Specialty Designation Request Form

PART A - GENERAL INFORMATION

PERSONAL INFORMATION

LAST NAME

FIRST NAME

MIDDLE INITIAL

SOCIAL SECURITY NUMBER

STREET ADDRESS

APT. OR P.O. BOX NO.

CITY, TOWN OR VILLAGE

STATE

ZIP CODE

HOME TELEPHONE NO.

COUNTY OF RESIDENCE

EMPLOYMENT INFORMATION

JOB TITLE

WORK TELEPHONE NO.

CURRENT EMPLOYER

WORK UNIT OR FACILITY NAME

OUTPATIENT (PART 822) SERVICE

YES

STREET ADDRESS

CITY, TOWN OR VILLAGE

STATE

ZIP CODE

CREDENTIAL INFORMATION

CHECK THE APPLICABLE BOX TO INDICATE THE CREDENTIAL WITH WHICH YOU ARE SEEKING TO ASSOCIATE YOUR GAMBLING SPECIALTY DESIGNATION.

CASAC

CREDENTIAL NO.: _______________

CPP

CREDENTIAL NO.: _______________

CPS

CREDENTIAL NO.: _______________

SPECIALTY DESIGNATION FEE

THERE IS A ONE-TIME NON-REFUNDABLE $25 SPECIALTY DESIGNATION FEE ASSOCIATED WITH THIS REQUEST FORM. WHERE INDICATED,

PLEASE ATTACH A CHECK O R MONEY ORDER MADE PAYABLE TO NYS O ASAS. PERSO NAL CHECKS WILL BE ACCEPTED, HOWEVER,

PLEASE BE AWARE THAT SUBMISSION OF A CERTIFIED CHECK OR MONEY ORDER WILL EXPEDITE THE PROCESSING OF YOUR REQUEST

FORM.

**DO NOT SEND CASH**

ATTACH PAYMENT HERE

AFFIRMATIONS AND CERTIFICATIONS

I, THE UNDERSIGNED APPLICANT, HAVE READ, UNDERSTAND, AND AGREE TO ABIDE BY, THE APPLICABLE CANON OF ETHICAL PRINCIPLES (ATTACHED) . I ATTEST THAT THE INFORMATION

CONTAINED IN THIS REQUEST FORM, INCLUDING ANY ATTACHMENTS, IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. I UNDERSTAND THAT IF THE INFORMATION SUBMITTED

CONTAINS A FALSE STATEMENT, MY REQUEST MAY BE DENIED AND I MAY BE PROSECUTED TO THE FULLEST EXTENT OF THE LAW. IF THE REQUEST IS APPROVED AND LATER

DETERMINED TO CONTAIN MATERIALS THAT WERE FALSE OR MISLEADING, THE NEW YORK STATE OFFICE OF ALCOHOLISM AND SUBSTANCE ABUSE SERVICES (OASAS) HAS THE

AUTHORITY TO DULY ANNUL, SUSPEND, LIMIT OR REVOKE THE CREDENTIAL AND/OR SPECIALTY DESIGNATION ISSUED.

I FURTHER UNDERSTAND THAT MY NAME AND CITY/STATE OF RESIDENCE, AS WELL AS MY CREDENTIAL NUMBER AND ITS DATE OF EXPIRATION, MAY BE MADE AVAILABLE TO THE PUBLIC

AS PART OF OASAS’ REGISTRY OF CREDENTIALED COUNSELORS AND PREVENTION PRACTITIONERS.

A PERSON IS GUILTY OF OFFERING A FALSE INSTRUMENT FOR FILING IN THE FIRST DEGREE WHEN, KNOWING THAT A WRITTEN INSTRUMENT CONTAINS A FALSE STATEMENT OR FALSE

INFORMATION AND, WITH INTENT TO DEFRAUD THE STATE OR ANY POLITICAL SUBDIVISION THEREOF, HE/SHE OFFERS OR PRESENTS IT TO A PUBLIC OFFICE OR PUBLIC SERVANT WITH

THE KNOWLEDGE OR BELIEF THAT IT WILL BE FILED WITH, REGISTERED OR RECORDED IN OR OTHERWISE BECOME PART OF THE RECORDS OF SUCH PUBLIC OFFICE OR PUBLIC

SERVANT.

OFFERING A FALSE INSTRUMENT FOR FILING IN THE FIRST DEGREE IS A CLASS E FELONY.

APPLICANT SIGNATURE

DATE

PDS-37(7/13)