Application to Become a HeartMath Certified Trainer HeartMath® Certified Trainer Program Application Save my progress and resume later | Resume a previously saved form Resume Later In order to be able to resume this form later, please enter your email and choose a password. Your Email: A Password: Confirm Password: Welcome - Thank you for your interest in HeartMath® programs. Once we receive your application, a HeartMath representative will contact you to discuss program details and answer your questions. What type of training license are you applying for?Independent TrainerOrganizational Internal Trainer Name First Name M.I. Last Name Suffix Company Info Company Organization Title Department Address & Contact Information Address City StatePlease select... AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY AB BC MB NB NF NT NS ON PE QC SK YT Zip CountryPlease select... 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Lauderdale, FL - Jan. 25-29, '18 - Registration closes Dec. 7, '17 New Orleans, LA - March 15-19, '18 - Registration closes Feb. 1, '18 Boulder Creek, CA - May 10-14, '18 - Registration closes Mar. 29, '18 What is your primary market? How many employees are in your organization? How many people do you plan to train in HeartMath programs in one year? Describe your experience with public speaking, training delivery and audio-visual technology.Please select... None Beginner Intermediate Advanced How did you hear about HeartMath?Please select... Event External Referral Partner Public Relations Seminar - Internal Seminar - Partner Tradeshow / Conference Web Webinar Word of mouth Workshop Other If you are already a HeartMath client/customer, who is your primary contact?Please select... N/A Brian Kabaker Bruce Cryer Carol Thompson Catherine Calarco Christiana Bishop Claudia Davenport Dan Bishop Deborah Rozman Delmus Walker Howard Martin Jeff Goelitz John White Katharina Pruneau Katherine Floriano Marije E Miller Paula Elliott Rebekah Jacobson Robert Browning Robert Massy Rollin McCraty Sarah Moor Sibyl Cryer Stephanie Herzog Tom Beckman Toni Roberts Which of the following HeartMath technology products do you currently own?emWave ProemWave2Inner Balance Trainer (iOS app)Inner Balance BluetoothOtherNone Page 3 Write a short bio with emphasis on your experience as a trainer and explain why you want to become a HeartMath® Trainer (1,000 character limit)?. Who in your organization supports your HeartMath training objectives? What is that person's title and role in the organization? Upon completion of the certification training, please indicate how you would prefer your name to appear on your certificate. AgreementIndependent Trainer License Agreement AgreementOrganization Trainer License Agreement I have read and agree to the terms and conditions in the HeartMath Trainer License Agreement.Yes Save my progress and resume later | Resume a previously saved form Need assistance with this form?