iPEC Certified Professional Coach Training Programs

Application for iPEC Certified Coach Training

NY21A — New York Metro
Admissions Director 866-72COACH admissions@ipeccoaching.com

Module I: 02/26/2010 - 02/28/2010
Module II: 05/21/2010 - 05/23/2010
Module III: 08/20/2010 - 08/22/2010

Module IV:

Please fill out the form below and submit it online, or print it and fax or mail it.

1. Contact Information (items in RED are required)
First Name
Last Name
Address 1
Address 2
City
State/Province
Zip/Postal
Country
Preferred Phone
Second Phone
Cell Phone
Fax
Preferred Email
Confirm email
Second Email
Website
iPEC Contact:
Other
What will be your coaching focus?

2. Personal Assessment
The following information will help us evaluate your potential as a professional coach and any particular areas that need development. Please rate the following statements:
	a. I consider myself to be a leader.
	b. I make my decisions based on inner values.
	c. I am non-judgmental.
	d. I usually have a strong opinion on issues.
	e. I have something unique to offer others.
	f. I work well with all kinds of people.
	g. I am a good listener.
	h. I am very optimistic about life.

3. Education
Education	Date Graduated	Certificate/Degree
High School
College
Graduate School
Alternative/ professional certifications/training
Other education or training:
Please specify:

4. Work Experience
Dates	Company	Position/ Responsibility






5. Personal Skills and Attributes
List any specific skills that you believe will help you as a professional coach.

What are the personal qualities you have that you think would be an asset as a coach?

6. Areas of Interest
Are there any specific areas of coaching in which you are particularly interested?

7. Statement of Purpose
Write a few paragraphs as to why you want to become a Certified Professional Coach. Please include a line or two about why you believe this is the right time for you to become a coach.

Class for which you are registering:
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