CERTIFICATION REQUESTED: $150 $220 $270 CERTIFICATION APPLICATION Effective Through December 31, 2019 APPLICANT: First Name: Middle: Last: Address: City: State: Zip Code: Highest Degree: Institution: Major: Professional Certifications Held 1 : CEERI/KPEERI Exam Passage Date: APPLICANT AFFIRMATION I affirm that all of the information provided on this application is true and accurate and fully responsive to the questions asked. I have read and agree to abide by the Code of Ethics of the Center for Effective Reading Instruction that are found within the CERI Certification Handbook. I agree to abide by all standards required to maintain my certification, including payment of annual fees and participation in continuing professional development activities, and I understand that, once certified, my certification status may be made available to the public. Legal Name Date SUBMISSION OF APPLICATION MATERIALS Email: cblevins@dyslexiaida.org.. Please write CERTIFICATION APPLICATION in the subject line. Snail Mail: The Center for Effective Reading Instruction Attention: Christy Blevins (Certification Application) 40 York Road, 4 th Floor Baltimore, MD 21204 1 Please attach a copy of your professional certifications. 1
Preparer: Applicant Preparer Attestation Form Preparer has clearance to supervise practicum through affiliation with: Accredited Institution of Higher Education: / Institution Program Accredited Partner Organization: / Organization Credential Held Attestation: My signature, below, attests that I have supervised the above-named candidate s professional practicum portfolio and have determined that s/he meets/ does not meet the necessary coursework and/or practicum requirements to be awarded the requested certification. Printed Name: Signature: Title: Address: City: Zip: Applicant: Seeking: per 2
Certification Sponsor Attestation Form Overview When Required: When an applicant wishes to document that they have completed a training and practicum experience that is equivalent to those required for certification, but: 1. These experiences were not completed under the direction and guidance of an Accredited institution or organization; or, 2. The institution or organization they trained under was Accredited at the time they were undergoing training, but is no longer Accredited; or, 3. The organization they trained under is no longer in practice; or, 4. They ve lost their practicum evaluation documentation; or, 5. They ve been practicing as a tutor for students with dyslexia for more than 10 years, with local, state, or national recognition, but have no formal documentation of having completed a supervised practicum experience. How: Applicant must prepare a professional portfolio that includes all necessary components, as documented below, and submit this portfolio to an individual approved to supervise practicum candidates through their affiliation with an Accredited Institution of Higher Education or an Accredited Partner Organization. This individual will serve as the applicant s sponsor. The sponsor will review the applicant s professional portfolio and sign the Certification Sponsor Attestation Form to indicate whether or not the candidate does or does not meet the necessary coursework and/or practicum requirements to be awarded the requested certification. The applicant will submit the signed Certification Sponsor Attestation Form with their application. per 3
Sponsor: Certification Sponsor Attestation Form Sponsor has clearance to supervise practicum through affiliation with: Accredited Institution of Higher Education: / Institution Program Accredited Partner Organization: / Organization Credential Held Attestation: My signature, below, attests that I have reviewed the above-named candidate s professional practicum portfolio according to the approved criteria established by my affiliated Accredited Institution or Organization, and have determined that s/he meets/ does not meet the necessary coursework and/or practicum requirements to be awarded the requested certification. Name: Title: Address: City: Zip: Applicant: Seeking: per 4
Credit Card Authorization Payment Form Cardholder Name: (Exact name as it appears on credit card) Name of Applicant (if different than the card holder): Billing Address: Cardholder Phone Number: Credit Card Type: Visa MasterCard AMEX Discover Credit Card Number: Expiration Date: / (mm/yy) Card Identification Number (last 3 digits located on the back of the credit card): Amount to Charge: $ (USD) (acceptance fee only) I authorize IDA to charge the agreed amount listed above to my credit card provided herein. I agree that I will pay for this purchase in accordance with the issuing bank cardholder agreement. I understand this is only for one charge at this time. If additional charges are going to be authorized a new form will have to be completed. Signature of Card Holder: Date: 5