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
NO
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)