Application for Certified Sex Offender Treatment Provider (CSOTP)
Date: ______________________
Name (as it appears on your license, registration, credential or membership):
____________________________
Street Address: ________ __________
City: _______________ State/Territory:
Postal Code: __________ Country:
Phone: ____________________________
Email Address: ______________
I attest to the following (please initial each):
I am a licensed, registered, credential or membered professional as outlined in Criterion 1.1 of the Certification
Standards
My professional license, registration, credential or membership is current and in good standing as outlined in
Evergreen Certifications’ Code of Ethics
I have completed the required training as outlined in Criterion 2.1 of the Certification Standards
____ I have completed a minimum of 2,000 clinical hours under supervision, with 200 of those hours specific to the
evaluation and treatment of sex offender clients as outlined in Criterion 3.0 of the Certification Standards
I verify that this application is complete, accurate, and that the information provided and attested to is factual and true.
I understand that if any of the information provided and attested to is false or found to be false, my certification will be
denied and/or revoked, and my licensing board may be contacted. I understand that information submitted with this
application may be verified for accuracy by Evergreen Certifications. I also agree to contact Evergreen Certifications in
the event I no longer meet the requirements to be a Certified Sex Offender Treatment Provider (CSOTP).
Signed: ______________________________________________________________ Date: ______________________
