Kolbe Certification Application

Instructions

We’re excited to have you apply to become a Kolbe Certified™ Consultant. Completing this application allows us to learn more about you and affords us the chance to customize the training in order to meet your needs. So thank you, in advance, for supplying us with your information. We greatly appreciate it, and you!

I am applying to attend the Kolbe Certification Seminar on:

Month

Year

My Account Manager’s name is:*

Title*

First Name*

Last Name*

Preferred Name

(ex: Bill vs. William)

Preferred Pronouns

(ex: she/her/hers)

Other Preferred Pronouns

(ex: ze/zir/zirs)

Company Name*

Job Title*

Provide a short description of your company and the type of industry:*

Total # of employees:*

# of employees at your location :*

Your Company’s Street Address:*

City:*

State/Province:*

Please use the abbreviation for your state/province

Zip Code:*

Country:*

Work Phone: *

Cell Phone: *

Fax:

Work Email*

Home Street Address:*

City:*

State/Province:*

Please use the abbreviation for your state/province

Zip Code:*

Country:*

Personal Phone:*

Personal Email:*

Preferred Method of Contact:

Call*

WorkPersonal

Email*

WorkPersonal

Please ship pre-seminar materials to:*

Work AddressPersonal Address

Please provide work and education experience:

Please list any education beyond high school, including institution and degree/major*

Other work experience for the last 10 years, including company and job title*

(You may paste LinkedIn URL if it is up to date)

Resume Upload

List other relevant training or certifications you have?*

(e.g. other assessments)

Do you have any of the following Human Resources professional certifications? (Select all that apply)

SHRMHRCIICF

Please list your Kolbe A™ Index result (M.O.)*

Have you taken the Kolbe A Index more than once?*

YesNo

Please list all known results of your Kolbe A™ index:*

Can you give us a few details as to why you retook the Kolbe A™ index?

i.e. First result was in Transition; was changing jobs; going through life event; child going off to college, etc.

Have you taken the Kolbe B™ Index for your current position?*

YesNo

Please list the Kolbe B™ Index result for your current position.*

Are you currently working with a Kolbe Certified™ Consultant? If so, please list their name:

Please list a reference (can use Kolbe Certified Consultant info if you answered “yes” to the above)*

	Name	Company Name	Email	Phone Number

Who can we thank for introducing you to Kolbe? *

List any other assessments used by your company:*

Please explain how you propose to use the knowledge gained from Kolbe Certification in your business*

I choose one of the following options:*

I will be using my Kolbe External Specialist (KES) status to market Kolbe services to a broad range of clients outside of my organization as an External ConsultantI will be using my Kolbe Specialist (KS) status to deliver Kolbe services only within my own organization.I have been given prior permission for an alternate purpose such as Researcher.

Have You Attended:

Our 3 or 4-day Kolbe Certification program?*

YesNo

Year*

Our annual conference (CNS, KolbeCon)?*

YesNo

Year*

Other Kolbe Workshops?*

YesNo

Workshop Name

If attending in person, do you have dietary restrictions?*

YesNoI am attending virtually

Please explain your dietary restrictions:*

I give Kolbe Corp permission to photograph or video record me during the Kolbe Certification Seminar. I understand that this may be used by Kolbe Corp for in-house and outside marketing purposes in electronic, print or new media formats.*

YesNo

I give permission to include my contact information and image on a class roster distributed to seminar attendees. This information is only provided to those who attend your Kolbe Certification class.*

YesNo

May we use your LinkedIn image/photo as your contact photo?*

YesNo

Copy/paste your LinkedIn URL here: copy/paste complete URL* (Click your picture on LinkedIn, then copy the URL address in your browser and paste it here)

(Note: If not, you will be asked to submit a photo)

Photo Upload

I agree to the following terms (please initial each term to indicate agreement):

I understand that one of the requirements is to attend and participate in all scheduled days of the training. If I miss any portion of the scheduled training, including arriving late or leaving early, my Kolbe Certified™ status may be in jeopardy.*

Initial

In order to maintain Kolbe Certified status, I must keep up-to-date with continuing education requirements set by Kolbe Corp, (7 credits per year). I also understand there are Consultant Membership Fees charged annually.*

Initial

If a corporation paid for me to become Certified, my Kolbe Certification status is held by the corporation. If I leave the corporation, I will need to reapply to become a Kolbe External Specialist (KES) or a Kolbe Specialist (KS).*

Initial

If I fail to successfully complete the Certification process, or if Certification is withheld for any reason, Kolbe Corp is not obligated to refund any amounts previously paid by my organization or by me for the Certification Seminar.*

Initial

The total price of Certification will be billed upon approval of your application and includes a $250 non-refundable application fee.*

Initial

A 50% cancellation fee will be retained by Kolbe Corp if I do not cancel at least ten (10) business days before the scheduled Seminar start date.*

Initial

I understand that canceling my attendance or changing dates for a virtual Kolbe Certification™ Training after materials have been shipped may result in an additional fee of up to $150.*

Initial

Kolbe Corp will refund 50% of the fee paid (minus the $250 non-refundable application fee) if I do not attend Certification within one year of the Seminar for which I originally applied.*

Initial

Electronic Signature

Acknowledgement*

I understand, and agree to, the above terms and attest that the information submitted is accurate.

I verify that all of the information I have provided is true to the best of my knowledge.

Date*

Date

Thank you! Our Training Team will be in touch with you as your application moves through the approval process.

Kolbe Certification™ Seminar Application