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Print This Page Full name:________________________________________________________________ Mailing address:____________________________________________________________ _________________________________________________________________________ City:_____________________________ State: ________________ Zip Code: __________ Country:____________ Daytime phone: (________ )_________________________ Evening phone: (______)_______________ Email:_______________________________
Designation(s) I desire (upon successful
completion of each certification designation training program, which can
be done simultaneously with one another):
If I am
accepted by the Professional Certification Institute, I, and the
organization that I may represent, will always follow and abide by the
Code
of Ethics of P.C.I. I understand and agree that my professional
designations will be terminated if I violate the
Code of Ethics, or if I
do not pay my annual renewal PCI membership dues (currently $49.00 per
certification designation). To accompany this training application,
If you have completed ANY post-high school college, trade, or technical education programs of any kind, please provide the details including school name, school location, year of graduation or completion of course, subjects studied, and any other helpful info. Attach extra sheets of paper if needed. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Please describe in detail all or your business/work/career experiences that you believe would be helpful to your successful career as a certified environmental professional. [please include details such as skills learned, employer names and addresses, and dates]. Attach extra sheets of paper if needed. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Please provide the names, nature of relationship [how you know each person], company [if relevant], complete mailing address, and current phone number of at least three persons who personally know your work abilities and/or general character. Your most ideal references would be your business/professional clients or co-workers. Please do NOT submit references who are your relatives or employees. Attach extra sheets if needed. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ I certify that the above information is totally true and complete. I authorize my references to provide complete information about myself to the Professional Certification Institute. ___________________________________ ____________________
My
Signature
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