Application for HeartMath Interventions Certification HeartMath® Interventions Certification 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: Before submitting your application, please review the HeartMath Interventions Letter of Agreement, the terms of which you will need to agree to as part of the application process. Letter of Agreement YesI have read the HMI Letter of Agreement and I agree to the terms to be executed upon registration into the HMI program. HMI Letter of Agreement Once we receive your application, a HeartMath® representative will contact you to discuss program details and answer any questions. This program includes the Training, The emWave® Pro Plus with assessments, a Manual and four books – Transforming Anger, Anxiety, Depression and Stress. Name First Name M.I. Last Name Suffix Address & Contact Information Company Address City Please 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 State Zip Please select... United States Canada Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos ( Keeling ) Islands Colombia Comoros Congo Cook Islands Costa Rica Côte d ' Ivoire Croatia ( Hrvatska ) Cuba Cyprus Czech Republic Congo ( DRC ) Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands ( Islas Malvinas ) Faroe Islands Fiji Islands Finland France French Guiana French Polynesia French Southern and Antarctic Lands Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong SAR Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao SAR Macedonia, Former Yugoslav Republic of Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Samoa San Marino São Tomé and Prìncipe Saudi Arabia Senegal Serbia and Montenegro Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands Spain Sri Lanka St. Helena St. Kitts and Nevis St. Lucia St. Pierre and Miquelon St. Vincent and the Grenadines Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Viet Nam Virgin Islands ( British ) Virgin Islands Wallis and Futuna Yemen Zambia Zimbabwe Country Email Address Daytime Phone Mobile Phone Please list the professional licenses and/or credentials you currently hold: Include Type, Number, State & Expiration: Where do you treat most of your clients ? Include facility and address: If you are not already a HeartMath client/customer, who were you referred by? Upon completion of the certification option, please indicate how you prefer your name to appear on your certificate. E.g. Janet Conner, Ph.D. Save my progress and resume later | Resume a previously saved form Need assistance with this form?