Fillable PCB Gambling Endorsement Application (Pennsylvania Certification Board)

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PCB Gambling Endorsement Application (Pennsylvania Certification Board)

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File type: PDF

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Revised January 2021
INFORMATION & DIRECTIONS
The Certificate of Competency in Problem Gambling is an endorsement available only to those professionals who meet
the education requirement. Credentials must be current, valid, and in good standing.
The endorsement can be obtained at any time once the education requirement is met. The expiration date of the
endorsement will be the same as the initial, qualifying credential. You must renew the endorsement with your qualifying
credential to maintain it. Your endorsement will be added to your certificate of your qualifying credential.
CHECKLIST
□ Completed application page.
□ Documentation of education.
□ Application fee.
If there are any issues with the application, you will be notified by email. Applications are open for one year after the
date of review. If an applicant fails to fulfill endorsement requirements within that year, the application will be closed,
and no refund will be issued.
If there are any problems with the application, you will be notified by email. Keep a photocopy of the entire application
for your records.
REQUIREMENTS: CERTIFICATE OF COMPETENCY IN PROBLEM GAMBLING
PREREQUISITE: CAAC, CADC, CAADC, CCJP, CCDP, CCDPD or CCS that is in good standing.
EDUCATION: 30 hours of problem gambling specific education/training. Education is defined as formal, structured
instruction: workshops, seminars, in-services, college/university credit courses and online education.
APPLICATION FEE: $100
RECERTIFICATION
To maintain the Certificate of Competency in Problem Gambling, recertification is required every two years. The
professional will submit the recertification application with the requirements for their qualifying credential and must
include six hours of approved gambling specific education.
ENDORSEMENT APPLICATION
Certificate of Competency in Problem Gambling
PCB | Certificate of Competency in Problem Gambling Application | Revised January 2021 2
ENDORSEMENT APPLICATION: GAMBLING
Form can be completed and saved. You may then print the appropriate pages to submit to PCB.
TYPE OR PRINT LEGIBLY
PCB PREREQUITE CREDENTIAL: □ CAAC □ CADC □ CAADC □ CCJP □ CCDP □ CCDPD □ CCS
Date:
DOB:
□ Male
□ Female
Name:
SSN: (last four)
Home Address:
City:
State:
Zip:
Cell Phone:
Email:
Have you ever received any disciplinary action from another certification or licensing authority since your
last application or recertification? □ Yes □ No If yes, provide full details on a separate sheet.
PAYMENT INFORMATION: $100 FEE MUST ACCOMPANY APPLICATION
PAYMENT (CHECK ONE): □ Check □ Money Order □ VISA □ MasterCard □ Discover □ American Express
Checks & Money Orders made payable to PCB
Email address for receipt (credit card only): _____________________________________________________
TO SUBMIT YOUR APPLICATION, CHOOSE ONE OF THE FOLLOWING:
• MAIL: PCB: 298 S. Progress Avenue | Harrisburg, PA 17109
• EMAIL: info@pacertboard.org NOTE: Only PDFs are acceptable. PCB does not accept photos of
applications.
• FAX: 717-540-4458
Please allow 5-10 business days for review and processing of your application.
To confirm receipt of your application, or check on the status, email info@pacertboard.org.
Number:
-
-
-
Sec. Code:
Exp. Date:
Name on Card:
Billing address:
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PCB Gambling Endorsement Application (Pennsylvania Certification Board)

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Completed 3 June 2021

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