ATP Application Form
Name to be printed on certificate:
_________________________________________________________
Mailing Address: ____________________________________________________
City: ________________________State: ________Zip Code:_____
Phone Number: _________________________________________
Fax Number: ___________________________________________
E-mail Address: _________________________________________________________
Name of Institution/tutor program: __________________________________________________________________________________________________________________
Certification Level Requested:
|
Certification |
New |
Renewal |
|
Associate Tutor* |
$10.00 |
$5.00 |
|
Advanced Tutor* |
$20.00 |
$10.00 |
|
Master Tutor* |
$30.00 |
$15.00 |
|
Tutor Trainer* |
$40.00 |
$20.00 |
|
Master Tutor Trainer* |
$50.00 |
$25.00 |
*Associate, Advanced and Master Tutor certification please send one original and three copies to:
Ms. Beth Nikopoulos Brookhaven College 3939 Valley View Lane Farmer Branch TX 75244*Tutor Trainer and Master Tutor Trainer certification please send one original and three copies to:
Dr.Cora Dzubak Penn State - York 1031 Edgecomb Avenue York, PA 17403