Certified Program Director Form

If you do not wish to use this online form, you can download this Application for Program Director PDF file and mail it to us.

Application for Program Director

Please complete all information, and sign and date before submitting.

Applicant Information
Your Name*
As you wish it to appear on your certificate
Your Birth Date*
Date Format: MM slash DD slash YYYY
Your Email*
Enter Email Confirm Email
Address*
Street Address Address Line 2 City State ZIP Code
Training Information
Name of the church, ministry, or person that supervises your ministry in the Overcomers program*
Address*
Street Address Address Line 2 City State ZIP Code
Pastor or Supervisor's Name*
Chruch / Organization Phone Number*
Date you completed workbook - A Daily Choice*
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 organization or person who sponsored the Leadership Training Seminar you completed*
Please upload a scanned image or PDF of your instructor's certificate if you have it
Accepted file types: jpg, gif, png, pdf.
Signature*
Today's Date*
Date Format: MM slash DD slash YYYY
Additional Information
If you were an alcoholic, or addict, your sobriety date
Date Format: MM slash DD slash YYYY
Your addictions were
Facilitated 90-day groups
Name and address of organization(s) where you FACILITATED two required 90-day groups
Name of church, prison or organization
Instructor's name
Address
Street Address Address Line 2 City State ZIP Code
Name of church, prison or organization
Instructor's name
Address
Street Address Address Line 2 City State ZIP Code
New Groups
The two NEW groups you have established, if different from above.
Name of church, prison or organization
New Instructor's name
Address
Street Address Address Line 2 City State ZIP Code
Name of church, prison or organization
New Instructor's name
Address
Street Address Address Line 2 City State ZIP Code
How often do you schedule Leadership Training Seminars?
How can we better assist you?

Application for Program Director

Applicant Information

Training Information

Additional Information

Facilitated 90-day groups

New Groups