*Name:

*Address (street, city, state, zip):



*Business Phone:

Home Phone:

FAX:

*E-mail:


Professional Title:


Describe your organization (school system, private practice, state agency, rehab center) types of clients you work with, and any associates who will assist you in conducting the AIT listening sessions:

Highest Educational Level Achieved:

High School
College
Grad. Degree
Prof. Degree

List current degrees, professional licenses and enclose copies of all certificates, diplomas, licenses, etc. Include Date, Degree, University/College, Field of Study:

List past five years of related professional work experience, starting with the most current:

Have you had previous experience with any type of sound interventions? Please describe.

List related non-professional experience, starting with the most current:

Professional Associations to which you belong:

CEU's: Are you interested in obtaining CEU's?

Yes
No

A certificate of completion for CEU's can be provided for you to turn in to your local agency. Pre-approval is often required, so be sure to check on this.

How soon would you like to receive training?:
(format: mm/dd/yyyy)

To the best of my knowledge, the information above is correct.

Signature


Date