Please Check One -- New Renewal

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

Last Name_____________________________________ First Name_______________________________

Institution or Corporate Affiliation ____________________________________________________________
(Including Certification Affiliate)

Address ___________________________________________________________Home/School (circle one)

City ______________________________________________ State ________________ Zip ____________

Phone ______________________________________ FAX _______________________________________

Email __________________________________________________________________________________

Current Position or Title ___________________________________________________________________

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

Individual   Basic Intermediate Advanced Master   

Academic Coach  Trainer  Master Trainer  Mentor 

Program     Curriculum   

Please contact your commercial or academic learning center to see if they are registered as an NTA Certification Affiliate, in which case streamlined certification processing, verification of practical tutoring hours, references and criminal background check may be available from them.

INITIAL APPLICATION CATEGORIES AND FEES (Check One)

RENEWAL APPLICATION CATEGORIES AND FEES (Check One)

For NTA Members applying for initial NTA certification or certification renewal from outside the U.S., please include $19.95 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 unofficial transcripts with their initial certification applications. Renewal applicants need to supply 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). Proof may take the form of logs, parent letters, time sheets, letters from supervisors, etc. 

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

All private practice applicants (anyone over age 18) must submit background check documents and an additional background check processing fee: $55. 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 __________________________