APPLICATION to QUALIFY FOR
CDROM PURCHASE
and MENTORSHIP PROGRAM
Directions: If you want to purchase the CDROM system of
ergonomic analysis and training and/or want to be mentored, you need to submit the application below. If you attended our workshop,
“Ergonomic Worksite Analysis: Theory and Practice for Growth and
Profitability” and already own the CDROM, you still need to complete the
application if you want to be mentored. The application is required for
membership in the Worksite International Network. To complete this application, please
print out this form and submit it by mail with the required attachments to
Worksite International.
Click
here to learn about the certification opportunities with the Oxford Research
Institute
Contact Information:
Application Date:_______
Name: ____________________________________________________________
Company: _________________________________________________________
Address: __________________________________________________________
Work Phone: ___________________________Home Phone________________
Fax: _______________________________________
E-mail: _____________________________________Web:__________________
1. Male Female
2. Highest level of education: BA/BS MA/MS PhD
Certification
3. APTA Member: Yes No
4. State License or Certification Number_______________
5. Please list the Ergonomic Courses that you have attended, the location
and the date of attendance:
| Course Title |
Instructor |
Location |
Date Attended |
| |
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Approved CE Courses include but are not limited to: University of
Michigan, UC Berkeley, Back School of Atlanta, Matheson 5 day program,
Isernhagen and Assoc., Impacc, Worksite International, Oxford Research
Institute.
6. Professional Practice: PT OT RN Vocational Rehab Safety Other ____________________
7. Years of Experience in the profession: _______________________
8. Check the box if you have performed more than two of the following:
a. Office Ergonomic Worksite
Analysis Estimated #
performed_____________
b. Industrial Ergonomic Worksite Analysis
Estimated # performed____________
c. Training in Ergonomics for
employees Estimated # performed
_____________
d. Limited to no experience at all
9. Mentorship Desired: (You must have a copy of the Worksite
International CDROM System of Ergonomic Worksite Analysis and Training)
Basic Mentorship (included with CDROM purchase)
Advanced Mentorship- contact Worksite International for details
Both programs
10. Please select two of the following questions and write a brief essay.
Please attach a separate sheet of your responses.
1. What are your professional business objectives in the field of
ergonomics?
2. What are your competencies?
3. What are the issues you struggle with in your practice?
4. Why are you applying for this program?
5. What do you hope to gain from being a part of the Worksite
International Network?
Statement of Understanding:
I understand the Worksite International Basic Mentorship program is
provided only in reference to using the Worksite International System of
Ergonomic Analysis and Training. Once I complete the basic mentorship process, I
have met the criteria to become a participating member of the Worksite
International Network of Ergonomic Service Providers (WIN). I also understand
that I will receive a "Letter of Completion" indicating I have
successfully completed the evaluation and training components of the WI Basic
Mentorship Program. At my option, this letter can then be submitted along with
my application to the Oxford Research Institute for board certification in
ergonomics. If I qualify as an Industrial Ergonomist, I understand I am
eligible to receive my specialty designation as a Worksite International
System Assessment Specialist.
_____________________________________________________________________
Signature
Date
Check off the program you are interested in.
CDROM and Mentorship:
$495.00 + 7.25 % tax (CA only) + $6.95 S/H
Multi-user license and Mentorship:
$295.00. Each user must apply
separately.
Advanced Mentorship
3-6 month program - To learn more, click here.
WIN membership for Licensed WI System Specialists: $135.00/year
Already paid for CDROM and mentorship as I attended training on
_____________(date)__ in ___________(city).
Your Submission must include the following:
Completed application with your essay response (Question #10).
A copy of professional license or certificate.
A copy of the CEU Certification/proof of attendance that you attended
ergonomics training.
A floppy disk or CDROM with a100 word Biography about your
professional interests in ergonomics, work injury prevention and management and a digital photo in Word 97 or
2000 (photo is optional but preferred for the website).
Payment if indicated.
___________________________________________________________________________________________
Payment Enclosed:
Send to: Worksite International 887 Abrego Street Monterey, CA 93940
Check payable to Worksite International
Credit Card Visa MasterCard
American Express
Account Number _______________________________________
Expiration Date ________________________________________
Signature _____________________________________________
Print Name _____________________________________________
Your application must contain all the requested criteria in order to
receive the CDROM and qualify for the mentorship program. Payment will not be accepted
otherwise. Please contact Worksite International at 888-288-4463 or alisonh@worksiteinternational.com
if you have any questions.
Modified 06/08/2006
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