1. PROGRAM LIAISON/CONTACT PERSONS AND MAILING ADDRESS:

2. CERTIFICATION LEVELS REQUESTED (please check appropriate box/boxes):

 3. APPLICATION FEE: $75.00

Please submit a check for $75.00 payable to "CRLA/Tutor Certification." Attach check to this application form. The Federal I.D. # is 95-3177158. PO'S are not acceptable at this time.

4. Information and Document Checklist: Please complete this checklist before mailing to make sure your application is complete.

NOTE: YOU MAY APPLY FOR MORE THAN ONE LEVEL FOR A PROGRAM AT ONE TIME, BUT IF YOU ARE APPLYING FOR MORE THAN ONE PROGRAM, YOU MUST SUBMIT COMPLETE APPLICATIONS FOR EACH SEPARATELY.

DO NOT SUBMIT APPLICATIONS FOR NEW LEVELS OR NEW PROGRAMS TOGETHER WITH A RECERTIFICATION APPLICATION.

____ 1. Contact Person, Institution, and Program to be certified is identified above in each copy of the application.

____ 2. Certification Levels requested are checked above.

____ 3. Check for application fee of $75 is attached to this page on the original copy of the application.

____ 4. 1-2 page narrative overview follows this page in each copy of the application.

____ 5. Verifications follow the narrative in each copy of the application.

____ 6. Labeled Documentation is tabbed and cross-referenced to each verification category in each copy of the application.