Please Check One -- New Renewal

(Circle One) Mr. Mrs. Ms. Dr.

Last Name_____________________________________ First Name_______________________________

Institution or Corporate Affiliation ____________________________________________________________
(Including Learning Center Affiliates)

Address ___________________________________________________________Is this your home or office?

City ______________________________________________ State ________________ Zip ____________

Phone ______________________________________ FAX _______________________________________

Email __________________________________________________________________________________

Current Position or Title ___________________________________________________________________

I am applying for certification at the following level (circle one):

Individual Level I    Basic Intermediate Advanced   

Individual Level II    Basic Advanced  

Individual Level III    Basic Advanced  

Program     Curriculum   Academic Coach 

Special package fees are available to applicants who qualify via online training or testing:

*In New York the cost of the background check is increased by $150.

INITIAL APPLICATION CATEGORIES AND FEES (Check One)

RENEWAL APPLICATION CATEGORIES AND FEES (Check One)

For NTA Members applying for NTA Certification Renewal from outside the U.S., please include $10.00 additional for shipping and handling. Please send all payments in US funds.

If this is a renewal application, is this an upgraded certification level from your original certification ? Yes No

If this is a renewal application, what was the date of your original certification ? __________________________

Signed certification check-list, all required supporting documentation, any required permissions, and certification fees must accompany your application packet.

Please Make Checks Payable to the National Tutoring Association FEIN: 35-2196495

Mail Completed Application Packet to:
National Tutoring Association
Certification Programs
PO Box 6840
Lakeland, FL 33807-6840

Certification Application Checklist

Please sign and date this checklist. Include checklist with your certification application.

Applicants are required to submit official transcripts with their initial certification applications. Renewal applicants need to supply official transcripts only if the information has been changed or updated since initial certification.

Applicants are required to submit proof of practical tutorial hours served. (Learning Center Affiliates may supply this for their staff and tutors).

Applicants are required to submit proof of completion of NTA approved training.

All applicants (both new and renewal) are required to supply two letters of recommendation. These letters may be solicited from students, colleagues, peers, and/or supervisors. (Learning Center Affiliates may supply this for their staff and tutors).

Renewal applicants are required to supply detailed information regarding the number and type of CEU's earned for renewal.

All private practice applicants must submit background check documents and an additional background check processing fee: $45 Please note that due to state law, the processing fee is $195 if the candidate has ever resided in the State of New York. 1.Sterling Summary of Rights 2.Sterling Consent & Disclosure

Applicants are encouraged to attach any additional data, certificates, program descriptions, publications, manuals, etc., that may contribute to the support of the applicant's request for certification renewal.

Applications must be accompanied by the applicable fees.

Name (Please print) ______________________________________

Signature ______________________________________________

Date __________________________