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 Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming 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 Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming 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
