Contact Information

* 1. Full Name

* 2. Street Address

* 3. City, State, Zip Code

* 4. Daytime Phone

* 5. Evening Phone

* 6. Work E-mail Address

* 7. Personal E-mail Address

* 8. Full Legal Name (for Certificate)

* 9. Please indicate the lived experience that makes you eligible to serve as a peer to others seeking recovery from substance use disorders or mental health conditions. This indication of lived experience will drive the endorsement(s) applied to the issued credential. Applicants may hold multiple endorsements. You will answer the following questions based on your lived experience. For example, only those applying for CRPS-Family will answer from the perspective of a family member.
Applying for Endorsement (s)

* 10. Please mark all that apply:

* 11. I have started the application process through the Florida Certification Board to become a Certified Recovery Peer Specialist.