Fillable APPLICATION TO TRAIN FOR PCB (Pennsylvania Certification Board)

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APPLICATION TO TRAIN FOR PCB (Pennsylvania Certification Board)

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Country of origin: US
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APPLICATION TO TRAIN FOR PCB
PCB accepts applications to train from all professionals in behavioral health and related fields. Trainers are responsible
for all materials needed for
the presentation (PowerPoints, handouts, etc.) as well as laptops/computers.
PCB will
provide projectors and audio/visual equipment as requested.
All rooms will be set classroom or theater style. Trainers
are paid a stipend of $250 per 6-hour training. PCB will not underwrite travel expenses or lodging. Training submissions
should be 6 hours.
REQUIREMENTS
1. Summary of the training
2. Learning objectives and goals of the training
3. Bibliography
4. Trainer resume or CV
5. Two professional references with contact information
6. Documentation, summary and contact information from the last two organizations where you trained.
TRAINING APPLICATION
Form can be completed and saved. You may then print or email the application to submit to PCB.
TYPE OR PRINT LEGIBLY
Name:
Email:
Credential(s)/Degrees:
TRAINING INFORMATION
Title:
I confirm that the information given is true and complete to the best of my knowledge. I understand that if I am selected
to train, I am responsible for paying all travel related expenses and that PCB may check my professional references.
Signature:
Date:
TO SUBMIT YOUR APPLICATION, CHOOSE ONE OF THE FOLLOWING:
• EMAIL: education@pacertboard.org NOTE: Only PDFs are acceptable. PCB does not accept photos of applications.
• FAX: 717-540-4458
• MAIL: PCB: 298 S. Progress Avenue | Harrisburg, PA 17109
Address:
City:
State:
Zip:
Employer:
Title:
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APPLICATION TO TRAIN FOR PCB (Pennsylvania Certification Board)

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Completed 3 June 2021

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