All information submitted to us is used in CE Credit and order processing. We do not share any information with any outside parties whatsoever. Email Username Password Passwords should be 8 characters minimum, contain at least 1 capitalized letter, 1 number, and 1 lowercase letter. Password confirmation Newsletter Yes I want email notices of newsletter publications. Your Personal Account Information IMPORTANT Please be certain that your name is spelled and capitalized correctly as this is the name that will appear on your certificate! First name Last name Company Address 1 Address 2 City Country -- select country -- United States Canada State/Province ---Select State/Province--- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Puerto Rico Palau US Virgin Islands US Minor Outlying Islands Postal code Primary Phone Alternate Phone Fax Your Professional Information NOTE TO ALL FLORIDA LICENSED PROFESSIONALS. Florida licensed professionals must now provide this information for reporting to cebroker.com. Please include the letters and the numbers of your license - exclude the preceding zeros ALL OTHER STATES. The required fields below must be completed to receive certification. Identify your primary license, state where licensed, and license number. If you have multiple licenses, please identify a primary license which we can use to identify you. Interns can write “intern” after entering license type. If you have no license or certification please enter “none” in each of these fields. License Type/Profession License State/Province License # -- select profession -- Addictions Professional Behavior Analyst Behavioral Health Technician Criminal Justice Professional Employee Assistance Professional Marriage and Family Therapist Mental Health Counselor Professional Counselor Psychologist School Counselor School Psychologist Social Worker Nurse Other -- select state -- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Puerto Rico Palau US Virgin Islands US Minor Outlying Islands Add Another License Agree to Continue I have read and agree to Program Services fee and refund policies. Required Please type SAP below: By clicking "CONTINUE" you are accepting the terms and conditions set forth in the: User Agreement.
