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* 1. First and Last Name

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* 2. E-mail Address

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* 3. Phone #

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* 4. Fax #

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* 5. Mailing Address

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* 6. Mailing Address

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* 7. I am currently employed as a

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* 8. My highest academic degree is

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* 9. My academic area of study (Major)

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* 10. Are you licensed in your professional field?

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* 11. Are you nationally certified in your professional field?

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* 12. How many years have you worked in an educational setting post highest degree?

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* 13. How are you paying the fee for this certification?

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* 14. I would like CE credits (no additional fee) should I achieve certification. I would like these from the:

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* 15. How did you learn of our trainings? (social media, professional organization, membership call, colleague/friend, membership email, etc)

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* 16. I understand this application and the subsequent training materials are non-transferable.

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* 17. The undersigned, being hereby warned that intentional or unintentional false statements and the like so made may jeopardize the validity of the application, declares that he/she/they is properly authorized to execute this application; and that all statements made of his/her/they own knowledge are true; and that all statements made on information and belief are believed to be true. By typing your name below, you are signing this application electronically.

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* 18. I understand that by making payment on the next question, I am verifying that I am eligible to complete the course and understand it is non-refundable and non-transferrable.

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* 19. We have two fee rates. Select the appropriate one below.

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* 20. Upload proof of student status (current class schedule)

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