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APPLICATION FOR REGISTRATION





INTERNATIONAL APPLICATION FOR REGISTRATION

C O N F I D E N T I A L    I N F O R M A T I O N





RETURN THIS APPLICATION
WITH COMPLETE DOCUMENTATION TO THE:

International Administration of Clinical CounselorsÒ

    



Please return your current "Curriculum Vitae"
with this application and any supporting documents.







SECTION 1:  PERSONAL INFORMATION



1.  Applicant's FULL Name:
2.  Mailing Address:
3.  Counseling Center / Organization / Private Practice:
4.  Applicant's Title:
5.  Res. Phone: (        )    
6.  Bus. Phone: (        )


SECTION 2:  PROFESSIONAL REFERENCES


List two professional references who will assess your counseling/ministry skills
Reference forms must be completed by professional counselors, supervisors, counselor educators.

NAME:                    
ADDRESS:                            
TELEPHONE:                    
RELATIONSHIP:                    

NAME:                    
ADDRESS:                            
TELEPHONE:                    
RELATIONSHIP:    


SECTION 3:  PASTOR REFERENCE


List one Minister/Pastor reference who will assess your ministry skills
Reference forms must be completed  by  a minister/pastor

NAME:                    
ADDRESS:                            
TELEPHONE:                    
RELATIONSHIP:    


SECTION 4:  EDUCATION

Original Transcripts Are Requested

Institution:                        
Major Area of Study:    
Degree/Certificate:    
Dates Attended:

Institution:                        
Major Area of Study:    
Degree/Certificate:    
Dates Attended:

Institution:                        
Major Area of Study:    
Degree/Certificate:    
Dates Attended:

Institution:                        
Major Area of Study:    
Degree/Certificate:    
Dates Attended:

SECTION 5:  PRACTICUM (Supervised Counselor Training)

Original Transcripts Are Requested

Institution:
Major Area of Study:
Supervisor(s):
Dates Attended:

Institution:
Major Area of Study:
Supervisor(s):
Dates Attended:

Institution:
Major Area of Study:
Supervisor(s):
Dates Attended:

Institution:
Major Area of Study:
Supervisor(s):
Dates Attended:


SECTION 6:  SUPERVISION (Pastoral Counseling Experience)

Original Supervision Reports Are Requested

Supervisor's Name:
Organization/Agency:
From/To:

Supervisor's Name:
Organization/Agency:
From/To:

Supervisor's Name:
Organization/Agency:
From/To:

Supervisor's Name:
Organization/Agency:
From/To:


SECTION 7:  SUPERVISION (Clinical Experience)

Original Supervision Reports Are Requested

Supervisor's Name:
Organization/Agency:
From/To:

Supervisor's Name:
Organization/Agency:
From/To:

Supervisor's Name:
Organization/Agency:
From/To:

Supervisor's Name:
Organization/Agency:
From/To:



SECTION 8:   COUNSELING EXPERIENCE

Dates of Employment:
From/To:              
Hours Per Week:    
Total Years/Months:
Employer:
Address:
Supervisor's Name:
Title:
Your Position Title:
Telephone(     ):

Dates of Employment:
From/To:              
Hours Per Week:    
Total Years/Months:
Employer:
Address:
Supervisor's Name:
Title:
Your Position Title:
Telephone(     ):

Dates of Employment:
From/To:              
Hours Per Week:    
Total Years/Months:
Employer:
Address:
Supervisor's Name:
Title:
Your Position Title:
Telephone(     ):



SECTION 9:  I.A.C.C. CODE OF ETHICS


I.A.C.C. CODE OF ETHICS-Part 1:

As a professional Counseling Practitioner, I am bound and agree to the following articles of professional ethical conduct with the International Administration of Clinical Counselors.;

1. I will regard the well-being of the individuals I serve as my primary professional obligation.

2. I will fulfill my obligations and responsibilities with  integrity.

3. I will practice competently in the performance of the services and functions I undertake on behalf of the persons I counsel.

4. I will protect the confidentiality of all professionally acquired information. I will disclose such information only when properly authorized or when obligated legally or professionally to do so.

5. I will ensure that outside interests do not jeopardize my professional judgment or competence.

6. I will act to promote the utmost of  integrity and excellence in the Counseling profession.

7. The Counseling Practitioner will be able to apply the practice values of acceptance, self-determination and individuality without being discriminatory on any grounds of race, ethnicity, language, religion, marital status, gender, sexual orientation, age, abilities, socioeconomic status, political affiliation or national ancestry.

8. The Counseling Practitioner will possess reasonable moral principles especially in relation to truth and fair dealing and have personal qualities of honesty and sincerity.

9. Integrity is the foundation of professional counseling/ministry and therefore underlies each ethical declaration.

10. The Counseling Practitioner will identify and describe education, training, experience, professional affiliations, competence, nature of service, and actions in an honest and accurate manner.

11. I will be competent in the performance of the services and functions I undertake on behalf of the persons I serve.

12. The Counseling Practitioner will not undertake a matter of professional practice unless there is an honest belief in the competence to handle it. If sufficient ability cannot be attained without undue delay, risk or expense to the client, the Counseling Practitioner should either decline to act or obtain the client's consent to collaborate with, or refer to, a Counseling Practitioner or other professional who is competent on that matter.

13. The Counseling Practitioner will recognize that sufficient ability for a particular task may require advice from or collaboration with (experts in) other professional disciplines and will seek client agreement to work in these collaborative situations.

14. The Counseling Practitioner will recognize that personal problems and conflicts may interfere with professional effectiveness. Reasonable health and well-being will be maintained by the Counseling Practitioner as a recognized component of competent practice. If personal problems occur, reasonable care will be taken by the Counseling Practitioner to determine whether professional activities should be suspended, terminated or limited.

15. The Counseling Practitioner  will provide a quality of service which is at least equal to the standard of practice one would expect to receive in a like situation.

16. The Counseling Practitioner will have adequate knowledge and abilities to meet standard of practice requirements;

    16.1  knowledge and understanding of human development; cultural and environmental factors affecting human life and the patterns of social interactions contributing to the interdependence of human behavior.

    16.2  knowledge of interpersonal communications and interviewing processes.

    16.3  knowledge of intervention methods and change strategies.

    16.4  knowledge of professional ethics.

    16.5  knowledge of the limited reasons for terminating service;
- loss of client confidence
- prolonged failure of services to benefit the client
- further intervention unnecessary service offered or requested is unethical or criminal in nature

    16.6  Ability to use interpersonal; interviewing skills to provide clear explanations of professional and workable roles; to establish the expectation of mutual participation in the change process; to clarify the need to gather sufficient and appropriate information for understanding and assessment; to determine competence to consent; to implement the requirement of informed consent; to determine what must be disclosed to clients with respect to assessments, the nature of the helping process, alternative modes or intervention and innovative intervention possibilities.

    16.7  Ability to facilitate termination of service or referral to others in an orderly manner with a minimum amount of expense and other inconvenience to the client.

    16.8  Ability to keep clients informed of all relevant commitments and possible implications of their situation.

    16.9  Ability to notify a client within a reasonable interval when unable to meet a request.


    16.10  Ability to make a prompt and reasonable report when required.

    16.11  Ability to keep appointments with clients and answer all verbal and written communications in a reasonable time.

    16.12  Ability to arrange adequate coverage of work in times of absence.

    16.13  Ability to constructively contribute to the retention of support staff and to the maintenance of workplace facilities.

    16.14  Ability to respond reasonably to client dissatisfaction, early and directly.

    16.15  Ability to use consultation and supervision in the management of the professional relationship and the application of practice methods.

17. The Counseling Practitioner will recognize that sufficient ability for a particular task may require advice from or collaboration with experts in other professional disciplines and will seek client agreement to work in these collaborative situations.

18. The Counseling Practitioner will ensure that all information recorded is either relevant to the solution of the client(s) problems or is needed for others within the workplace setting who have need to know the information in the performance of their duties.

19. The Counseling Practitioner will make reasonable efforts to avoid recording information that would be against the best interests of the client should the case record be subpoenaed or seen by the client, and will promote the adoption of workplace procedures concerning the kind of information which does not belong in case records.

20. The Counseling Practitioner will include preliminary assessments, intervention plans and change strategies as part of a permanent record only for purposes of monitoring implementation of, progress toward, and response(s) to planned interventions.

21. The Counseling Practitioner must obtain informed consent or be reasonably satisfied of the client's incompetence to consent when it is proposed to use any electronic methods of recording actual work being done with the client.
The case record itself is the property of the self-employed Counseling Practitioner or the employer of the Counseling Practitioner and is, unless otherwise dictated by statute, the responsibility of the Counseling Practitioner or employer and subject to their control.
The Counseling Practitioner will respect the client's general right to know and will allow reasonable periodic opportunity to check the accuracy of all information that is recorded as fact and contained in the permanent case record of an agency.  In circumstances where client access to information contained in the record is dictated by statute, the law prescribes what access may or may not be permitted.

The client's general access to information contained in the case record may be refused for just and reasonable causes:  for example, when the work involves different members of a family or group and unrestricted access to the record could mean divulging personal confidences of others or when recorded language could be misunderstood and prejudicial to one of the members.  In such instances the Counseling Practitioner will allow individuals to check the accuracy of information pertaining only to themselves.  The Counseling Practitioner will not disclose the identity of persons who have sought professional counseling/ministry service or disclose sources of information about clients unless compelled legally or professionally to do so.

22. The obligation to maintain confidentiality continues indefinitely after the Counseling Practitioner has ceased contact with persons served.
The Counseling Practitioner will avoid unnecessary conversation regarding clients and their affairs, as matters overheard by persons without an official need to know may prove to be detrimental to the overall well-being of those being served.

23. The Counseling Practitioner may divulge confidential information with consent of the client, expressed in writing.

24. The Counseling Practitioner will transfer information to another agency or individual, only with the informed written consent of the client or guardian of the client and then only with reasonable assurance that the receiving agency provides the same guarantee of confidentiality and respect for the right of privileged communication as provided by the sending agency or practice. Disclosure of confidential information required by law or the policies of the workplace will be explained to the client, where reasonably possible, before such disclosure is made.

25. The Counseling Practitioner in practice with groups of people will notify the participants of the likelihood that aspects o their private lives may be revealed in the course of their work together, and therefore require a commitment from each member to respect the privileged and confidential nature of the communication between and among members of the client group(s).

26. The Counseling Practitioner in practice with families must safeguard the rights to privilege and confidentiality of information acquired concerning individuals in the couple or in the family.  Disclosure of information that one client has requested be kept confidential from his or her partner will not be made without the informed consent of the person providing the confidential information.  When one person provides consent to the release of confidential records or information, the release of confidential records or information, the Counseling Practitioner may release only information about the consenting person and must protect the confidentiality of all information derived form the non-consenting person(S).

27. Disclosure of information by the Counseling Practitioner may be justified to defend oneself, colleagues or employees against formal allegations of conduct unbecoming a professional, including malpractice and negligence, or to collect fees.  However, such disclosure must occur only to the extent necessary for such purposes.  

28. Disclosure of information necessary to prevent a crime, to prevent clients doing harm to themselves or to other is justified.  Such disclosure should be made with reasonable care and with the client's knowledge, unless information the client would impede the due process of law or violate the duty to warn others.  The discharge of this duty requires the Counseling Practitioner to take steps including but not limited to warning the intended victim or others who would likely apprise the victim of the danger, notifying the police, or taking whatever other steps are reasonably necessary under the circumstances

29. When disclosure is required by order of a court, the Counseling Practitioner should not divulge more information than is reasonably required and should where possible notify the client of this requirement.  In cases in which a subpoena is served to obtain confidential information bout a client, the Counseling Practitioner should attempt to protect the client's rights to privileged communication..  When such privilege is not clearly recognized, the Counseling Practitioner should obtain legal counsel and assert the claim of privilege that belongs to a client.

30. The Counseling Practitioner must take reasonable care to thoroughly disguise confidential information when using it for teaching, public education, accountability and research purposes.  When a client is presented to a scientific gathering, the Counseling Practitioner must obtain prior consent and prior confirmation that the confidentiality of the presentation is understood and accepted by the audience.  The Counseling Practitioner may present a client or former client to a public gathering or to the news media only if that client is fully informed of the loss of confidentiality, is competent to consent, and consents in writing without coercion.

31. The Counseling Practitioner will promote the adoption of policies and procedures concerning retention and disposition that will physically safeguard case records and personnel files against any anticipated threats or hazards to their security or integrity which would result in substantial harm, embarrassment, inconvenience or unfairness to any individual on whom information is maintained.

32. The Counseling Practitioner will not use case records and personnel files and the information contained in them for any purpose that is not consistent with the standard of practice set by this Code.

33. Where the Counseling Practitioner's documentation becomes part of the workplace's permanent record, retention or destruction of such records must be done in accordance with workplace policies which are consistent with the standard of practice set by this Code.

34. I will act to promote excellence in the Counseling profession.

35. The Counseling Practitioner will contribute reasonable time and professional expertise to activities that promote respect for the utility, the integrity and the competence of the Counseling/Ministry profession.

36. The Counseling Practitioner will protect and enhance the dignity and integrity of the profession and will be responsible and vigorous in discussion and criticism of the profession.

37. The Counseling Practitioner will take reasonable action against unethical conduct and unqualified practice of professional counseling.

38. The Counseling Practitioner/Minister will make reasonable efforts to prevent the unauthorized and unqualified practice of professional counseling.

39. The Counseling Practitioner will treat with respect and represent accurately and fairly the qualifications, views and findings of colleagues, and use appropriate channels to express judgments on these matters, confining such comments to matters of fact and matters of their own knowledge.

40. The Counseling Practitioner will not solicit the clients of colleagues.

41. The Counseling Practitioner will not assume professional responsibility for the clients of another agency or a colleague without appropriate communication with that agency of colleague and consent of the client.

42. The Counseling Practitioner who serves the clients of colleagues during a temporary absence or emergency will serve those clients with the same consideration as that afforded any client.

43. The Counseling Practitioner who replaces or is replaced by a colleague in professional practice will act with consideration for the interest, character and reputation of that colleague.

44. The Counseling Practitioner will not exploit a dispute between a colleague and employer to obtain a position or otherwise advance the Counseling Practitioner's own interests.

45. The Counseling Practitioner will seek arbitration or mediation when conflicts with colleagues require resolution for compelling professional reasons.

46. The Counseling Practitioner will extend to colleagues of other professions reasonable respect and cooperation.
The Counseling Practitioner engaged in research will ascertain that the consent of participants in the research is voluntary and informed, without any implied deprivations for penalty for refusal to participate, and with due regard for participant's privacy and dignity.

47. The Counseling Practitioner engaged in research will take reasonable actions to protect participants fro unwarranted physical or mental discomfort, distress, harm, danger or deprivation.

48. The Counseling Practitioner will take credit only for work actually done in connection with scholarly and research endeavors and will credit contributions by others.

49. The Counseling Practitioner is responsible for participation in reasonable periodic continuing education activities and is committed to a lifetime of learning.





STATEMENT OF PROFESSIONAL ETHICS AND CONDUCT



DECLARATION OF NON LEGAL ACTION:

I, (NAME PRINTED HERE), certify that under no circumstances has legal action been taken against myself in regards to my work in the area of counseling/ministry.



AFFIRMATION OF GOOD LEGAL STANDING:

Please answer the following questions. Each question must be answered in order to complete this application.

Œ Have you ever been found by any other professional association to which you have belonged to have violated its ethical code, or are you currently under investigation for an ethical violation by any other professional organization to which you belong?                                                                                                                                            o  Yes   o   No

Have you ever had your registration, certificate or license to practice therapy suspended, revoked, restricted, or denied or has any other disciplinary action been taken against you by any federal or state regulatory body or foreign jurisdiction, or are you presently under investigation by any regulatory body, to the best of your knowledge                                                            o   Yes   o   No

Have you ever had privileges to practice therapy in a hospital, etc. suspended or restricted or any other disciplinary action been taken against you on grounds of unprofessional conduct, incompetence, negligence, or unsafe practices?                                                                                                                                                    o   Yes   o   No

Have you ever been convicted of a felony or convicted of any misdemeanor which might relate to the practice of therapy?                                                                                                                                                            o   Yes   o   No

Has any claim been made against you in a civil suit or any other forum in the past ten years which clearly alleges unethical behavior on your part including but not limited to, the following examples:  sexual intimacy with a client, a dual relationship with a client, violation of confidentiality, and so forth?  If yes, please provide an explanation.                                                                                                                                                                                        o  Yes   o   No

Have you ever voluntarily given up privileges, registration, certificate or license to practice therapy, or agreed to restrict your practice in lieu of or to avoid formal action?                                                                                        o   Yes   o   No

If you answered "yes" to any of the above,
please provide detailed information



CONFIRMATION AND RELEASE STATEMENT:

I affirm that the above statements in this application are true.

I hereby give permission to the INTERNATIONAL ADMINISTRATION OF CLINICAL COUNSELORS (I.A.C.C.) to request appropriate information regarding the action(s) named above from the relevant regulatory body, professional association, agency or court, and authorize I.A.C.C. to communicate with all persons listed as my endorsers, teachers, supervisors, or superiors as the Administration shall deem necessary.

With the submission of this application, I agree to abide by the INTERNATIONAL ADMINISTRATION OF CLINICAL COUNSELORS Code of Ethics.

I understand that registration with the I.A.C.C. does not in and of itself imply or specify licensure to practice counseling for a fee, monetary or otherwise.  If I am granted registration by I.A.C.C. and practice counseling as a private practitioner, I do so at my own risk.  I hereby release the I.A.C.C. from any and all liability and/or claims that may arise from any decision to practice privately as a registered Counseling Practitioner.

I understand that registration depends upon my fulfillment of all required criteria for registration, including application of the I.A.C.C. Code of Ethics in Professional Practice. I also understand that I am obligated to inform I.A.C.C. if I am involved in an ethical inquiry or a criminal investigation

Upon accepted registration, I understand that professional biographical data is considered to be public information and will be available in response to consumer inquiries. I understand that all material becomes the property of  I.A.C.C. upon receipt and that neither originals nor photocopies will be returned to me.





CRIMINAL RECORDS CHECK

To be completed by your local Law Enforcement Agency

Police Agency:     
File #

Full name of applicant:

Maiden Name:
Birthplace:
Driver's License #:
Birthdate:
Telephone:    
Address:

WHEREAS I have applied for I.A.C.C. MEMBERSHIP and am required to disclose whether or not I have any convictions or have been charged under any Federal, Provincial or State enactment;

AND WHEREAS I understand that disclosure of a criminal record may not necessarily preclude me from the function I have applied for;

AND WHEREAS I understand that, if the INTERNATIONAL ADMINISTRATION OF CLINICAL COUNSELORS should decide any conviction or charge disclosed might preclude me from the function I have applied for, I will be given an opportunity to see and discuss the criminal record;

I, therefore, authorize the (Police Agency), on my behalf, to inquire into and determine whether or not I have a criminal record, and also make to the INTERNATIONAL ADMINISTRATION OF CLINICAL COUNSELORS a full and complete disclosure of any criminal record they might find.

To this end, I herewith affix my signature.

Signature                                 
Date:

Authorization for Fingerprinting

If there is a requirement to verify that I do or do not have a criminal record, the police will require my fingerprints. I understand that my fingerprints will be returned to me after this check has been completed.


Signature                                 
Date:

To:  Police Agency:

The noted applicant has consented to release information to this organization.  Please check the applicant's record and indicate the results on this form.



Police Use Only - Results of Records Check

Results of records search is merely a record, or lack, of official contact with police agencies, not an affirmation of good character.

A search of: 1. the Central Repository for Criminal Records
                      2. index of Detachment

In the above name and birthdate shows:

_____no record
_____a record exists on local index, and a copy, certified by the applicant is attached
_____a Central Repository Record may exist but cannot be disclosed unless verified by fingerprint comparison.
_____no outstanding charges
_____there is (are) an outstanding charge(s)


(Police Detachment Member)                            

Date




PASTOR RECOMMENDATION


INTERNATIONAL ADMINISTRATION OF CLINICAL COUNSELORSÒ


Applicant's Name:

The person named above has applied to the INTERNATIONAL ADMINISTRATION OF CLINICAL COUNSELORS to become Registered as a Counseling Practitioner/Ministers. Your assessment of the applicant's characteristics will enable the I.A.C.C. to evaluate whether this applicant meets its standards.  This is a confidential document and will not be released to the applicant without your written consent. Please respond to all questions to the best of your ability.  (Questions 1,2, and 3 apply to the person completing form).

Pastors Name:
Degree:
Church Address:
Position Title:
Telephone:(     )
Education:
Relationship with the Applicant:

In view of your knowledge of the applicant, how do you assess his/her abilities and character in the following categories?                                                    
Intellectual ability:

Ability to work with others:

Initiative:

Maturity:

Interpersonal Skills:

Self-confidence:

Self-discipline:

Oral communication skills    :

Leadership Skills:

Aptitude for chosen profession:


Please rate the applicant compared to other Professional Counselors you know on the following characteristics.  
                                            

Individual counseling skills:

Personal integrity    :

Ability to relate to co-workers:

Ability to be objective on the job:

Ethical conduct:

Concern for welfare of clients:

Sense of responsibility:

Supervisory abilities:

Ability to keep material confidential:

Spiritual gifts:

Ability to pray for clients needs:



FORM #1: PROFESSIONAL REFERENCE ASSESSMENT - Part 1


INTERNATIONAL ADMINISTRATION OF CLINICAL COUNSELORSÒ


Applicant's Name:

The person named above has applied to the INTERNATIONAL ADMINISTRATION OF  CLINICAL COUNSELORS to become Registered as a Certified Counselor/Minister. Your assessment of the applicant's characteristics will enable the I.A.C.C. to evaluate whether this applicant meets its standards.  This is a confidential document and will not be released to the applicant without your written consent. Please respond to all questions to the best of your ability.  (Questions 1,2, and 3 apply to the person completing form).

Reference's Name:

Business Address:
Profession:
Degree:
Position Title:Telephone:(     )

Certification:

Certifying Organization:
Relationship with the Applicant:

Please rate the applicant compared to other Professional Counselors you know on the following characteristics.  
                                            Individual counseling skills:

Personal integrity    :

Ability to relate to co-workers:

Ability to be objective on the job:

Ethical conduct:

Concern for welfare of clients:

Sense of responsibility:

Supervisory abilities:

Ability to keep material confidential:

Spiritual gifts:

Ability to pray for clients needs:

Ethical conduct:

Concern for welfare of clients:

Sense of responsibility:

Recognition of own limits:

Supervisory abilities:

Ability to keep material confidential:

Spiritual gifts:

Ability to pray for clients needs:


FORM #1: PROFESSIONAL REFERENCE ASSESSMENT - Part 2


INTERNATIONAL ADMINISTRATION OF CLINICAL COUNSELORSÒ


Applicant's Name:

The person named above has applied to the INTERNATIONAL ADMINISTRATION OF  CLINICAL COUNSELORS to become Registered as a Certified Counselor/Minister. Your assessment of the applicant's characteristics will enable the I.A.C.C. to evaluate whether this applicant meets its standards.  This is a confidential document and will not be released to the applicant without your written consent. Please respond to all questions to the best of your ability.  (Questions 1,2, and 3 apply to the person completing form).

Reference's Name:

Business Address:
Profession:
Degree:
Position Title:Telephone:(     )

Certification:

Certifying Organization:
Relationship with the Applicant:

Please rate the applicant compared to other Professional Counselors you know on the following characteristics.  
                                            Individual counseling skills:

Personal integrity    :

Ability to relate to co-workers:

Ability to be objective on the job:

Ethical conduct:

Concern for welfare of clients:

Sense of responsibility:

Supervisory abilities:

Ability to keep material confidential:

Spiritual gifts:

Ability to pray for clients needs:

Ethical conduct:

Concern for welfare of clients:

Sense of responsibility:

Recognition of own limits:

Supervisory abilities:

Ability to keep material confidential:

Spiritual gifts:

Ability to pray for clients needs:



FORM #1: PROFESSIONAL REFERENCE ASSESSMENT - Part 2


INTERNATIONAL ADMINISTRATION OF CLINICAL COUNSELORSÒ


Applicant's Name:


FOR SUPERVISORS ONLY:  If you are verifying applicant's experience, you must complete this section.  I verify that this applicant for membership as a Professional Counselor/Minister has spent

amount of time                                    under my supervision in the following capacity:
            

                                            
Applicant's Position                    Name of Agency/Institution                                                        

from                                    to                                                                                                            
        Date                                    

Write any additional comments here please.

Recommendation:  I recommend this applicant for registration as a Professional Counselor/Minister for client/patient referral with I.A.C.C.    
o  Yes   o  No

If no, please explain:

The above information is based upon my best judgment.  I am willing to answer additional questions concerning this evaluation if the I.A.C.C. deems it necessary.


                
Signature of reference                            Date                                                                    






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