Collegiate Strength and Conditioning Coaches Association

C E R T I F I C A T I O N A P P L I C A T I O N
F O R M A Y 2 0 0 9 E X A M I N A T I O N

Application Deadline: March 10, 2009
Fields marked (*) are required

First Name:*

MI:

Last Name:*

Name for Certificate:*: NOTE: Please write your name exactly as you would like it to appear on your certificate.

Mailing Address:*: Home Work

Street:*

Street 2:

City:*

State:*

Zip:*

Work Phone:*

Cell Phone:

Fax:

Email:

University or Professional Athletic Team where you are currently employed :: (Full-time Strength & Conditioning Coaches Only)

Where was your practicum / internship / residency / graduate assistantship completed: (Only if you were not a full-time S&C Coach as of September 1, 2000)

University / College:

From:

To:

Current CPR Certification Expiration Date:

List any other certifications which you currenty hold:

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