* 1. Date

Date:
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* 2. Please provide the following information:

* 3. In what areas would you like to receive training? (select all that apply)

* 4. Are you interested in substance abuse curriculum training?

* 5. If so, which one(s)

* 6. How many training hours are you required to get a year for your certification?

* 7. How far are you willing to travel to attend a training?

* 8. What kind of CEU's do you need?

* 9. Please provide any recommendations you have for topics and/or presenters for future trainings.

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