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

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:                         $595.00 + 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 1213 Miles Ave Pacific Grove, CA 93950

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.