1515 S Street, 212 North
Sacramento, CA 95811
NOTE: All fees are considered final. There will be no refunds. Payments are valid for 6 months
Applicants are responsible for any returned check fees.
For CASOMB Certification Unit Staff:
Check #: _________________________
Amount Paid: ____________________
App Emailed: _____________________
Thank you for your interest in (re)certifying your Provider Agency with the California Sex
Offender Management Board. The first step in the certification process is to remit your
application payment and the details below.
The fields below are required to be issued a login to CASOMB’s online application system. Note
that application fee covers the cost of review; accepted payment does not
guarantee the
applicant will meet the qualifications for CASOMB certification. Please provide a preferred email
where you would like login information sent. Upon receipt of payment, login instructions will be
emailed to your preferred email address within 3-5 business days.
CASOMB Provider Agency Name:
Clinical Director First Name:
Clinical Director Last Name:
Clinical Director Email:
Applicant Phone Number:
Alternate Contact Name:
Alternate Contact Email:
Number of Treatment sites:
Please Select Only One:
New Application: 1-10 Clients ($90.00) 11-40 Clients ($120.00) 41+ Clients ($180.00)
Recertification: 1-10 Clients ($50.00) 11-40 Clients ($65.00) 41+ Clients ($100.00)
Make checks payable to ‘CASOMB’. Mail this completed form and check to:
CASOMB Certification Unit
1515 S Street, 212-North
Sacramento, CA 95811