LEVEL V – Entrance Application Form
Master Trainer in CD and Organization
NAME:
Last
First
Business Name:
Street Address
Unit Number
City
Phone:
State/Province
Day:
Zip/Postal Code
Country
Evening:
Fax:
E-mail:
Qualification 1)
I am a member in good standing of the NSGCD
Initial
Qualification 2)
I am currently working professionally with at least one CD client.
Initial
Qualification 3)
I received my CPO-CD® credential on
Month/Year
Qualification 4)
I received my Training Program Coach credential on
Month/Year
Waiver form is required for those receiving their Level IV Training Program Coach designation prior to 2 years (24
months) of this application’s date. See http://www.nsgcd.org/certification/apps/NSGCDWaiverApplication.pdf
07/28/10
Qualification 5) I agree to the following Level V Commitments and Program Obligations
a. Accomplish one Coach & Mentor task within two years of submitting this application. Note to applicants:
these tasks may have been completed up to two years prior to this application as long as they haven’t
been previously applied to Level III or I requirements.
b. Accomplish two different Create, Teach, & Lead tasks within two years of submitting this application.
Note to applicants: these tasks may have been completed up to two years prior to this application as long
as they haven’t been previously applied to Level III or IV requirements.
c. Pay $100.00 US dollars application fee (includes $25.00 non-refundable application fee).
d. Recertify every three years to maintain my Level V Master Trainer in CD and Organization credential.
(The alternative is to recertify at Level III or IV and relinquish your Master Trainer status.)
My signature indicates I am willing to abide by the Commitments and Program Obligations.
Signature:
Date:
I have
Initialed Qualifications #1 and #2
Annotated CPO-CD® credential date (Qualification #3)
Annotated Training Program Coach designation date (Qualification #4)
Enclosed a check (payable to NSGCD) for $100.00 in US Funds
Given my credit card information for payment
Please apply to my:
Credit Card #:
V code
VISA
MasterCard
Discover
American Express
Exp. Date:
(3-digit code on the back of the card)
Billing Address if different from above
Authorization signature:
Please mail or fax completed application & fee to:
NSGCD
Certification Program-Level V Application
1693 S. Hanley Rd
St. Louis, MO 63144
fax: 314-845-1891
AND Please email completed application to:
CertificationDir@nsgcd.org
07/28/10