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

  • As you wish it to appear on your certificate
  • Date Format: MM slash DD slash YYYY
  • Training Information

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Accepted file types: jpg, gif, png, pdf.
  • Date Format: MM slash DD slash YYYY
  • Additional Information

  • Date Format: MM slash DD slash YYYY
  • Facilitated 90-day groups

    Name and address of organization(s) where you FACILITATED two required 90-day groups
  • New Groups

    The two NEW groups you have established, if different from above.