Peer Certification Reimbursement Application

Please complete and submit the following online application for the consideration and reimbursement of either the Certified Peer Recovery Specialist (CPRS) certification through the Addiction Professionals Certification Board of NJ (APCBNJ); the National Certified Peer Recovery Support Specialist (NCPRSS) through the National Certification for Addiction Professional (NCC-AP) credential application fee, or any applicable testing fees.

Funding for scholarships is provided by the New Jersey Department of Human Services, Division of Mental Health and Addiction Services State Opioid Response grant. In order to be eligible for this reimbursement scholarship a person must be either working in or volunteering for an approved DMHAS funded peer initiative and have a valid certification.

For questions, please contact Breyonna Kelton at 732-367-0611 or Breyonna@njpn.org.

First name*

Last name*

Email*

Phone number*

Street address*

Please enter your home mailing address, your reimbursment check will be mailed to this address.

City*

State/Region*

Postal code*

Organization/Agency:*

Peer Certification Status:*

Please select only one option.

Certified Peer Recovery Specialist (CPRS)

National Certified Peer Recovery Support Specialist (NCPRSS)

Submitted CPRS Application

Submitted NCPRSS Application

Supervisor First Name*

Supervisor Last Name*

Supervisor Phone Number*

Supervisor Email Address*

Receipt(s) indicating payment was made for application fee and/or test fee:*

Copy of Certification:*

Completed W9 Form:*

A blank copy of the W9 form can be found here: https://www.irs.gov/pub/irs-pdf/fw9.pdf