Certification Application Form and Checklist for Mentors

Certification Application Form / Checklist for Mentors

NOTE: This form is ONLY for applicants who have completed the required training. Click the button for Training Requirements.
Please proceed only after you have fulfilled the required training
for certification.

TRAINING REQUIREMENTS

Directions: Fill out the Application Form and Certification Application Checklist on this page. Then, go to the Checkout for Professional mentor Certification page. There you'll be able to purchase the appropriate certification level.

* Indicates required field

Please Check One: *

New Renewal

Certification Application Form

Name *

First

Last

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Current Position or Title *

Institution or Corporate Affiliation or SELF *

Email *

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

Select one: *

Basic Mentor Advanced Mentor

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? *

Certification Application Checklist

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, SUCH AS VERIFICATION FROM AN NTA CERTIFIED TRAINER OR THEIR ORGANIZATION THAT CONDUCTS TRAINING WITH A CERTIFIED NTA TRAINER ON STAFF. *

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. PROOF MAY TAKE THE FORM OF LOGS, PARENT LETTERS, TIME SHEETS, LETTERS FROM SUPERVISORS, ETC. *

ALL PRIVATE PRACTICE APPLICANTS (ANYONE OVER AGE 18) MUST SUBMIT BACKGROUND CHECK DOCUMENTS AND AN ADDITIONAL BACKGROUND CHECK PROCESSING FEE: $65. *

In order to process your background check, as well as manage all of your certification documents, please proceed to castlebranch.com. Go to "Place Order" and enter the code NG50. Hit "enter." Scroll down the page and check that you "read, understand and agree to the Disclaimer. Click on "Continue." Complete all personal information and continue through the background check information and permissions process. You will be charged $65.00 for this service. You will also be required to upload other required certification documents through the CastleBranch system. All documents and background check results will be securely reported to the National Tutoring Association and must be approved before your certification will be issued.

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. * *

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

Digital Signature *

First

Last

Date *

Submit