Mold Training Application

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Please complete this PCI training application by neat printing and legible black ink, along with your signature,
and send to PCI by email attachment to: moldconsultant@yahoo.com, or FAX it [inside USA] toll-free to
1-877-572-5724, or outside of the USA to USA fax number 973-297-2860

Full name:___________________________________________________________________

Mailing address:______________________________________________________________

___________________________________________________________________________

City:_____________________________ State: ________________ Zip Code: ___________

Country:____________ Daytime phone: (________ )_________________________

Evening phone: (_______)_______________ Email address:___________________________

Designation [s] I desire [upon successful completion of each certification designation training program]---:
     ____ Certified Mold Inspector---tuition $499.00 plus first year membership certification dues in PCI of $49.00 for a total of $548.00
      ____ Certified Mold Remediator--tuition $499.00 plus first year membership certification dues in PCI of $49.00 for a total of $548.00
     ____ Certified Environmental Hygienist--tuition $499.00 plus first year membership certification dues in PCI of $49.00 for a total of $548.00
     ____ Certified Water Leak Locator--tuition $499.00 plus first year membership certification dues in PCI of $49.00 for a total of $548.00
     ____ Certified Waterproofing Pro--tuition $499.00 plus first year membership certification dues in PCI of $49.00 for a total of $548.00
     ____ Combo #1: These FOUR courses: ________________________________________________________
for the price of $1,497, plus US$196 first year membership certification dues in PCI for four designations, for a total of $1,693.
    ____ Combo #2: ALL FIVE courses for the price of $1,996, with a waiver of my first year membership certification dues in PCI for all five designations
          All payments are in US$ or the equivalent value of another widely-accepted currency.

If I am accepted by the Professional Certification Institute, I, and the organization that I may represent, will always follow and abide by the Code of Ethics of P.C.I. I understand and agree that my professional designations will be terminated if I violate the Code of Ethics, or if I do not pay my annual renewal PCI membership dues [currently $49.00 per certification designation]. To accompany this training application, I will process a payment to PCI using one of the Payment Options listed at the bottom this page, or by my check.

If you have completed ANY post-high school college, trade, or technical education programs of any kind, please provide the details including school name, school location, year of graduation or completion of course, subjects studied, and any other helpful info. Attach extra sheets of paper if needed.

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Please describe in detail all or your business/work/career experiences that you believe would be helpful to your successful career as a certified environmental professional. [please include details such as skills learned, employer names and addresses, and dates]. Attach extra sheets of paper if needed.

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Please provide the names, nature of relationship [how you know each person], company [if relevant], complete mailing address, and current phone number of at least three persons who personally know your work abilities and/or general character. Your most ideal references would be your business/professional clients or co-workers. Please do NOT submit references who are your relatives or employees. Attach extra sheets if needed.

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I certify that the above information is totally true and complete. I authorize my references to provide complete information about myself to the Professional Certification Institute.

___________________________________ ____________________

My Signature Date