CI Program Application 

Please complete all the questions on this application. This information will be sent to the CIW Certified Instructor (CIW CI) Program Department when you press "Submit".

** required field

Applicant Information:
First Name: **
Middle Name:
Last Name: **
Mailing Address 1: **
Address 2:
City: **
State/Province:
Postal Code:
Country: **	AlbaniaAlgeriaAmerican SamoaAntigua (including Barbuda)ArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBermudaBoliviaBosnia-HerzegovinaBrazilBritish Virgin IslandsBruneiBulgariaCambodiaCameroon, United Republic OfCanadaCayman IslandsChileChinaColombiaCongoCosta RicaCroatiaCyprusCzech RepublicDenmarkDominican RepublicEcuadorEgyptEl SalvadorEstoniaFiji IslandsFinlandFranceGambiaGermanyGhanaGreeceGrenadaGuatemalaGuyanaHondurasHong KongHungaryIcelandIndiaIndonesiaIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKuwaitLatviaLebanonLibyaLithuaniaLuxembourgMacaoMacedonia, Republic ofMalawiMalaysiaMaltaMauritiusMexicoMonacoMoroccoMozambiqueMyanmarNetherlandsNew ZealandNicaraguaNigeriaNorwayOmanPakistanPanama, Republic OfPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaSaudi ArabiaSingapore, Republic OfSlovakiaSloveniaSouth AfricaSouth KoreaSpainSri LankaSt LuciaSt VincentSwedenSwitzerlandSyriaTaiwanTanzaniaThailandTrinidad and TobagoTunisiaTurkeyU.S. Virgin IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUSAUzbekistan TashkentVenezuelaVietnamYemenYugoslavia, Federated States of
Phone Number: **
Fax Number:
E-mail Address: **

Employer Information:
CIW ATP ID Number: (optional)
Company Name: **
Company Address 1:
Address 2:
City:
State/Province:
Postal Code:
Country:	AlbaniaAlgeriaAmerican SamoaAntigua (including Barbuda)ArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBermudaBoliviaBosnia-HerzegovinaBrazilBritish Virgin IslandsBruneiBulgariaCambodiaCameroon, United Republic OfCanadaCayman IslandsChileChinaColombiaCongoCosta RicaCroatiaCyprusCzech RepublicDenmarkDominican RepublicEcuadorEgyptEl SalvadorEstoniaFiji IslandsFinlandFranceGambiaGermanyGhanaGreeceGrenadaGuatemalaGuyanaHondurasHong KongHungaryIcelandIndiaIndonesiaIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKuwaitLatviaLebanonLibyaLithuaniaLuxembourgMacaoMacedonia, Republic ofMalawiMalaysiaMaltaMauritiusMexicoMonacoMoroccoMozambiqueMyanmarNetherlandsNew ZealandNicaraguaNigeriaNorwayOmanPakistanPanama, Republic OfPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaSaudi ArabiaSingapore, Republic OfSlovakiaSloveniaSouth AfricaSouth KoreaSpainSri LankaSt LuciaSt VincentSwedenSwitzerlandSyriaTaiwanTanzaniaThailandTrinidad and TobagoTunisiaTurkeyU.S. Virgin IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUSAUzbekistan TashkentVenezuelaVietnamYemenYugoslavia, Federated States of
Phone Number:
Fax Number:
Current employment status: (select one of the following options) **
I am employed by a CIW Authorized Training Partner (CIW ATP)
I am employed by a company offering CIW courses (currently not a CIW ATP)
I am a Contract Instructor
Other
I would like to be added to a contract CIW Instructor list that will be made available to current CIW ATPs

Applicant Class Attendance Status:
Have you attended the CIW Foundations Course? **	Yes No
Please send all information via fax to the Prosoft Learning Certification Department at 602-794-4190 This is required of all CIW applicants unless you are a certified technical instructor (for instance an MCT, CTT or CNI) or a CIW Professional. See the CIW CI Program Guide for more details.

Applicant Certification Testing Status:
Have you passed the CIW Foundations exam? **	Yes No
Are you a CIW Professional? **	Yes No
Please send all information via fax to the Prosoft Learning Certification Department at 602-794-4190 The CompTIA i-Net+ exam does not apply to CIW Certified Instructor Approval. All CIW Certified Instructors must pass the CIW Foundations exam.

Applicant Certification Agreement Status:
Have you completed the CIW Certification Agreement? **	Yes No
If not, you will need to do so after completing this application.

Applicant Presentational Skills Status:
Do you have more than 1 year of experience as a Technical Instructor? **	Yes No
Have you attended a Train-the-Trainer? **	Yes No
Do you currently hold an Instructor Certification through another program (e.g. MCT, CTT, CNI)? **	Yes No
If yes, please specify:
Please send all information via fax to the Prosoft Learning Certification Department at 602-794-4190 This can include a technical instructor certificate or transcript, a Train-the-Trainer Certificate, an accredited teaching certificate, or a combination of a resume, 2 letters of recommendation and 10 student evaluations.

I would like to receive regular email CIW program updates.

I verify the content of this form to be accurate and complete to the best of my knowledge.

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