AIS Membership Application

Certified Intervention Professional (CIP) Certification is Required for Full Membership

Certified Intervention Professional (CIP)

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Please check which you are applying for

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Applicant Information

Zip Code/Postal Code

Phone Number

Work Experience Related to Interventions: (Where have you worked, when, what duties did you perform....)

Training and/or educational experiences related to Interventions (attach docs)

Style of Intervention (brief statement of philosophy)

Types of interventions offered – (AOD, Eating Disorders, Sexual Trauma, Gambling, etc....)

Geographical Locations (areas where you will facilitate interventions)

Other Services Offered

Credentials (Degrees, Licenses, certifications including first year received) Attach copies

Personal Statement

Verification

Digital Signature of Applicant: *

I authorize the verification of the information provided on this form as to my credit and employment.

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Step 2