CIS-EI Certification Provisional Application
This application is for all new CIS-EI providers who need to hold an EI Certification.
Personal Name
*
First Name
Last Name
Personal Email
*
example@example.com
Personal Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Please select the roles that you hold.
*
Early Interventionist/Developmental Educator
Service Coordinator
Supervisor or Early Intervention Staff
Other
If your role was not specified above, please list your role(s) here.
Please select the region that you work in.
*
Barre
Bennington
Brattleboro
Burlington
Middlebury
Morrisville
Newport
Rutland
St. Albans
St. Johnsbury
Springfield
White River Junction
Workplace Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Supervisor's Name
*
First Name
Last Name
Supervisor's Email Address
*
example@example.com
Supervisor's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Please list the highest degree you hold and your major(s) and concentration(s).
*
Please list the Vermont licenses and credentials that you hold.
*
All Provisional EI Certification applicants must complete the CIS-EI Module found on the Child Development Division’s learning management system, LINC. Your regional CIS Coordinator can grant you access. Have you completed the module?
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Yes
No
Did you complete the CIS EI Certification Quiz, found on the CIS Tools page under "CIS-EI Certification," and receive a score of 80% or higher? If you did not receive a score of 80% or higher, you can retake the quiz.
*
Yes
No
Submit
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