Upper Midwest Indian Council On
Addictive Disorders
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REGISTRATION
UMICAD Level I Exam – ICRC Written Exam (AODA and Clinical Supervisor)
Thursday - Friday, March 11-12, 2010
Bridgeview Motor Lodge
Superior, Wisconsin


Please complete & return to:
UMICAD
PO. Box 69
L’Anse, Michigan 49946
Ph. (906)524-4411 Fax. (906)524-4415
michael@umicad.org

Registration information (please print or type / one person per registration):


__________________________________________________________________
NAME

__________________________________________________________________
PROGRAM or AGENCY (if applicable)

__________________________________________________________________
MAILING ADDRESS (preferred)

__________________________________________________________________
CITY                                STATE                                ZIP CODE

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TELEPHONE                        FAX                                EMAIL

Enclosed registration fee
$250.00  - ICRC Written Exam - Friday,  12, 2010, March 9:00a.m.

$175.00 - ICRC Clinical Supervisor Exam - Friday, March 12, 2010 @ 9:00 a.m.

$100.00 - CPM (case presentation method exam, oral exam) March, 11, 2010 - please schedule a
time

$75.00 - UMICAD Level 1 exam - Thursday, March 11, 2010 @9:00 a.m.

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$                Total Amount

         
For Office Use Only
CHECK_________________________ PO #______________________CASH________________
Date Received:____________________________       

Comments:_____________________________________________________________________

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For your convenience please copy and print the registration form below: Mail or Fax the registration form no later than
11/19/2009 - Slots are limited
March 11 and 12, 2009 UMICAD Level I
Exam and ICRC AODA and Clinical
Supervisor Exam

Location: Bridgeview Motor Lodge
415 Hammond Ave
Superior, Wisconsin 54880
800-777-5572