Application Form

Please complete the information requested on this application form and return it with your nonrefundable application fee of $40 to:

Centerpoint Institute Certification Program
4000 NE 41st Street
Building D - Suite 2
Seattle, WA 98105-5428

I am applying for:     ____ Individual Track     ____ Group Track     ____ Both Tracks

Contact Information

Name

Street Address

City/State/Zip

Phones: Day____________________ Eve___________________ Cell____________________

Email Address

Educational Background   You may type this on a separate sheet, if you wish.

Undergraduate Institution

Degree___________________ Major____________________________

Graduation Date____________

Honors

Graduate Institution

Degree___________________ Major____________________________

Graduation Date____________

Honors

Additional Applicable Trainings:

Title

Dates______________________

Description

Title

Dates______________________

Description

Title

Dates______________________

Description

Experience  Below, please summarize your current and previous work experience or you may attach a resume.

Please include the job titles, places of employment, dates, and describe your responsibilities for each position.

Essay Questions  

What is it about this certification program that attracts you?

How do you imagine that you will benefit from your participation in this program?

How would you like to apply your learning of the Cycle of Change to your work with your clients, constituencies, and/or employees?

References

Please list three individuals who can address your ability to succeed in this certification program:

1) Name

Telephone______________________________  Email_____________________________________

Please describe your relationship with this person and what aspects of your abilities that they will be able to address:

2) Name

Telephone______________________________  Email_____________________________________

Please describe your relationship with this person and what aspects of your abilities that they will be able to address:

3) Name

Telephone______________________________  Email_____________________________________

Please describe your relationship with this person and what aspects of your abilities that they will be able to address:

Thank you for your interest in Centerpoint's Cycles of Change Certification Program!