MRCCB Credential Renewal Application Credential Renewal Submission Date Certification # * Renewal Date * Credentials Being Renewed Registered Peer Recovery Coach (RPRC) - $50 Certified Peer Recovery Coach (CPRC) - $75 Your Information First Name * Last Name * Address * Address House Number & Street House Number & Street Address Line 2 Address Line 2 City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Phone * Email Address * Has your address has changed since your last renewal? * Yes, my address has changed. No, my address is the same. Employment Information Are you currently employed? * Yes No Start Date Employer Employer Address Employer Address Number & Street Number & Street Address Line 2 Address Line 2 City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Has your work address has changed since your last renewal? * Yes, my work address has changed. No, my work address is the same. Work Email Position Title Supervisor Name If you are human, leave this field blank. Next
