Certified Instructor Form

If you prefer to download a PDF form, you can download the Application for Certified Instructor PDF here and mail it to us.

After meeting all requirements for certification, complete the following information, sign and date the form.

Applicant Information
Your Name*
Please enter this exactly as you wish it to appear on your certificate.
Address*
Street Address Address Line 2 City State ZIP Code
Preferred Phone Number*
Your Email Address*
Enter Email Confirm Email
Training Information
Name of the church, ministry or person training you*
Training Address*
Street Address Address Line 2 City State ZIP Code
Name of church / prison / place where you completed required group faciliation, if different from above
Date you completed required group faciliation*
Date Format: MM slash DD slash YYYY
Date you completed the Leadership Training Seminar*
Date Format: MM slash DD slash YYYY
If ex-prisoner. your release date
Date Format: MM slash DD slash YYYY
Name of place where you attended Leadership Training Seminar*
Name of person who hosted the Leadership Training Semniar*
Name and address to mail certificate
Certificate Name
Certificate Address
Street Address Address Line 2 City State ZIP Code
Your signature authorizes Overcomers, Inc., to verify the above information.
Signature*
Date*
Date Format: MM slash DD slash YYYY
Your Testimony
We love to hear testimonies of what the Lord has done in people’s lives through Overcomers. If you desire, please give us your brief Overcomers testimony. Unless you indicate otherwise, we may use portions of your testimony as encouragement on Overcomers Recovery Support’s Facebook page, newsletter, or other promotional materials.

Applicant Information