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Application to obtain CHDCA Certification via Mail (one application per student)

Name of applicant: ____________________________________________________________
Address: ____________________________________________________________________
City/State/Zip-Code: __________________________________________________________
Birthday: ____________________________________________________________________
Phone number: _____________________________ Fax Number: ______________________
E-mail: ______________________________________________________________________
Name of Company: ____________________________________________________________
Number of years that above company has been cleaning exhaust systems: _____________
Number of Years/Months of experience as a kitchen grease exhaust cleaner: ____________
Name of Proposed Proctor: _____________________________________________________
Address of Proctor: ___________________________________________________________
Phone number of Proctor: ______________________________________________________

I am currently certified by (IKECA) , (PWNA) or (Not Currently Certified). (circle one)

Please attach to this application the following:

• Make payment payable to:  Advanced Marketing
                                        110 Beverly Dr.
                                        Madison, TN 37115

• Photograph of yourself.  Passport Photo Torso shot, full color with solid light color background. (no group shots)

By signing this application I am verifying that the information submitted is correct to the best of my knowledge.  Falsifying information on this application will make your Certification null and void.  All information on your application and other submitted documents will be held in strict confidence and will not be released without your written permission.

Print Name: _________________________________________________________

Sign Name: _________________________________________________________