Application

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First Name_____________________________________________________________

M.I. __________________________________________________________________

Last Name ____________________________________________________________

Designation(s) _________________________________________________________

Organization or Firm Name  ______________________________________________

Mailing/Shipping Address--Line 1 __________________________________________

Mailing/Shipping Address--Line 2 __________________________________________

City State Zip Code  ____________________________________________________

Home Phone  _________________________________________________________

Work Phone  __________________________________________________________

Fax  _________________________________________________________________

Preferred E-mail Address ________________________________________________

Chapter Name _________________________________________________________

Member Number _______________________________________________________

Training Date __________________________________________________________

Trained By ____________________________________________________________

Training Date __________________________________________________________

Training Updated By  ____________________________________________________

Certified as a PLS in _____________________________________________________

Preferred Testing Site/City  _______________________________________________

Secondary Testing Site/City ______________________________________________ 

QUALIFICATIONS AND TRAINING

NALS members who have already obtained PP certification are encouraged to administer the PP, PLS, and ALS exams in their local area. Nonmember certified PPs may also administer the exams. Administrators may also be instructors who are employed by educational institutions. Administrators may assist with PP/PLS/ALS study groups within their chapters and states.
NOTE: PLSs may give the PLS and ALS exams and likewise ALSs can give the
ALS exam.

RECOMMENDATIONS

This  application requires two recommendations and can be any two of the following:  NALS board member, region director, state president, or chapter  president.  The undersigned hereby recommends _____________________  to serve as an exam administrator.

Date _______________  Name ________________________________________ Position ________________________      Signature_________________________   
Date _______________  Name ________________________________________ Position_______________________________________________________________     

Signature______________________________________________________________

AFFIRMATION: I, ___________________________ , having agreed to serve as an administrator of the PP, PLS, and ALS certification examinations, hereby
affirm as follows:
That I am a PP PLS ALS;

That I have completed the Administrator Training Manual. I further acknowledge that I understand the contents of the Administrator Training Manual and agree to comply therewith; That I hereby agree that I will not divulge the contents of any certification examination given by the NALS Certifying Board under penalty of revocation of my certification; and That I will sign a confidentiality statement each time I administer any certification examination.  Date______________  Signature ___________________________________________ 

FORWARD COMPLETED APPLICATION TO: 

Certification and Education Manager
NALS Resource Center
8159 East 41st Street
Tulsa, OK 74145

 

QUESTIONS?  COMMENTS?
Contact NALS Certification and Education Manager