Ecology College Training Application Form

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Please print, complete (in legible black ink printing), & sign this PCI training application, along
with the P.C.I. Code of Ethics, and send both this application and the signed Code of Ethics
to P.C.I. by email attachment to: moldconsultant@yahoo.com, or by FAX 1 (647) 439-1520 (Canada)

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):
     ____ Certified Mold Inspector---tuition $499.00 plus first year membership certification dues in PCI of $49.00 for a total of $548.00
      ____ Certified Mold Remediator--tuition $499.00 plus first year membership certification dues in PCI of $49.00 for a total of $548.00
      ____ Certified Environmental Hygienist--tuition $499.00 plus first year membership certification dues in PCI of $49.00 for a total of $548.00
      All payments are in US$.

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,
I will make payment to PCI by using one of the Credit Card Payment Options listed at the bottom this page,
or by my personal or business check, or money order payable to Professional Certification Institute.

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.

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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 Date