Resilient Educator^® Qualified Instructor Program Application

1. Which REQIP training dates do you want to attend?

   Please select a training date...March 23 - 26, 2012July 27 - 30, 2012October 26 - 29, 2012

Personal Information

1. First Name
2. Last Name
3. Occupation
4. How long have you been in this position?

1. (For shipping purposes, please no P.O. Boxes)
2. Home Address
3. City
4. State
5. Zip Code
6. Home Phone
7. Cell Phone
8. Website
9. E-mail Address

Will you be applying for an organizational license (school sponsored)?

1. Yes No

Or an Independent contract license?

1. Yes No

Organizational Contact Information

1. Organization Name
2. Address
3. City
4. State
5. Zip Code
6. Business Phone
7. Cell Phone
8. Fax
9. E-mail Address

General Information

Do you prefer to receive HeartMath materials at work or home?

1. Work Home

2. How did you hear about HeartMath?

Do you have an emWave^® Desktop?

1. Yes No

Do you prefer PC or Mac versions?

1. PC Mac

Do you have an emWave^®2?

1. Yes No

1. What HeartMath products or services have you used?

   Please include HeartMath workshops or seminars you may have attended.

1. What professional training have you received?

   Please include degrees, certifications and licenses held and dates completed.

1. Please describe the trainings you have presented.

1. Why do you want to become a licensed Resilient Educator Qualified Instructor?

1. List what potential schools or organizations you’ll approach in the next year.

1. Estimate the number of people you will serve with this program over the next year.

1. Include a brief summary of professional experience (500 characters max.)

1. Upon completion of the program you will receive a certificate. Please indicate how you prefer your name to appear on your certificate (e.g. Janet Connor, Ph.D.)

Reference Contact

Please list contact information for two references:

Reference Contact #1

1. Name
2. Phone
3. Organization & Title

Reference Contact #2

1. Name
2. Phone
3. Organization & Title