If you are interested in receiving an application for Prevention Certification, please complete this form and send it with appropriate fee to:
SCAPPA Certification Commission, PO Box 1763, Columbia, SC 29202, (803) 252-1087
Name: ___________________________________ Address: _______________________________________
City: _____________________________________ State: _________________ Zip Code: _______________
Phone: (Work) __________________________________ (Home) __________________________________
E-mail: __________________________________________ Fax: ___________________________________
Employer/School: _____________________________ Job/Position: __________________________________
Please send an application for: o Certified Prevention
Specialist
o Certified Senior Prevention
Specialist
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