APPLICATION FOR MEDITATION TEACHER CERTIFICATION

APPLICATION

BEING HUMAN - ENTELECHY INSTITUTE MEDITATION TEACHER TRAINING CERTIFICATE

Please complete the following information:

First Name

Last Name

Mailing Address: (Address Line1)

Address line 2 (optional)

City

State

Zip Code

Cell Phone

Email Address

Meditation Experience (please describe):

Do you currently teach meditation?

Yes No

Where did you complete your training?

Date of Completion

Number of Hours of Instruction

Education & Training

Academic Education

University/College that granted Degree

Degree Granted

Date

City

State

Graduate Education

University/College that granted Degree

Degree Granted

Date

City

State

Licensure or Certification

List current Licensure (include city and state of licensure) or Certifications:

State of Licensure

Employment

Current Employer

Position

Your Interests

Why do you want to teach Mindful Meditation?

What meditation practices have you been trained in, if any?

Please describe your present meditation practice, if you have one.

What are your expected outcomes and learning objectives for this program?

Upload a resume, CV or any supplemental materials

I, the undersigned, verify that this application is complete, and to the best of my knowledge, all information provided is factual and true.

Agreed:

Date