* Required fields
Name *
E-mail Address *
Have You Ever Been Convicted Of A Felony? *
Are You 18 Years Old Or Older? *
Have You Obtained a High School Diploma or High School Equivalency Diploma? *
Please List Your Name As You Want It To Appear On Your Certificate(s). *
Your Complete Mailing Address (Including Zip Code and Country). *
Daytime Phone Number *
Evening or Cell Phone Number *
Gender *
Please Indicate Your Desired Certification Program. *
Please indicate your desired program date. *
If you are completing an advanced (or add on) certification program, please choose your additional certification program. This is only for the 12-week Certified Life Coach (CLC) program. *
Are You Using the Payment Plan? *
If You Are Using a Payment Plan Do You Agree to Make Your Payments on Schedule? *
If you are using the payment plan and you would like your certification(s) when your program has ended please list your date of birth (This is only used if you default on your payments and we can't reach you). If this does not apply to you please put N/A. *
If you are using the payment plan and you would like your certification(s) when your program has ended please list the last 4 digits of your social security number (This is only used if you default on your payments and you can't be reached). If this does not apply to you please put N/A. *
If you are using the payment plan and you would like your certification(s) when your program has ended please provide the name of three references, and their telephone numbers (This is only used if you default on your payments, and you can't be reached). If this does not apply to you please ut N/A. *
If you are using the payment plan and you would like your certifications when your program has ended please list your employer's address and telephone number (This is only used if you default on your payments, and you can't be reached). If this does not apply to you please put N/A. *
Previous Certificates/Diplomas/Degrees *
Professional Background *
How Do You Plan On Using Your Certification? *
I agree to follow the ethical and professional guidelines of The CASE Institute. *
I agree that I don't have a history of unprofessional or unethical behavior that would interfere with me being certified. *
Please provide any additional information we may need to know.
How did you hear about us? *
Please type in your name and today's date to state that you agree with what is marked on this enrollment form. Once you submit this form please proceed to the Checkout/Make Payment page to complete your payment. We will electronically receive this form, and you will be sent your new student and class information within 24 hours. We strive to provide you the information within a few hours (excluding after business hours, holidays or weekends, then it will be the next business day). Thank you! *
Privacy Policy *
