Full Name (last name first):_______________________________________ A.K.A.______________

Street Adress:_____________________________________________

State:_____________ Zip Code:___________

Mailing Address If Different From Above:________________________________________________

Phone Number:_______________________ Fax Number:_______________________

Email Address:____________________________

Age:______

Male/Female:________

What is/are Your Riding Discipline(s)?:_________________________________________________

Number of Years Instructing (Please include skiing instruction experience if any):__________

Approximate Total Number of Hours of Snowboarding Instruction:_______________

Are You or Have You Ever Been a Certified Snowboard Instructor?:_____________

If Yes, What Organization Certified You?:__________________________________

If You Are Currently Certified, What is Your Level of Certification?:_____________

When Did You Recieve Your Last Level of Certification?:______________________

If No, What Prevented You From Acquiring Certification?:__________________________________

__________________________________________________________________________________

Are You Currently Employed By a Ski School or Snowboard Facility?:__________

Name of Employer:____________________________________________________

Address of Employer:__________________________________________________

State:_____________ Zip Code:___________

Mailing Address if Different From Above:________________________________________________

Phone Number:______________________

Name of Ski School Director or Facility Coordinator:_______________________________________

No Prior Certifications -

If you wish to apply for Level 100 Instructor certification and are currently not certified, please have your ski school director sign off on your total number of hours as an instructor and return this form to us. You must have 45 hours of snowboard instruction experience and be currently employed as an instructor.

Total Hours of Instruction:___________________

Director Signature:_________________________________

Cross-transfer Certification -

If you wish to obtain your Level 100 or Level 500 certification by cross-transfer, please forward to us your proof of certification and your certification level requirements along with this application.

For USSI Use Only

IID:__________ LECD:__________ CIL:__________ EMD:__________

PDIS:__________ SDIS:__________ TDIS:__________