CIS-EI Certification Renewal Application
This application is for CIS-EI providers who have held an Initial Full Certification or for five years and are now ready to apply for their Renewal Certification. This application is also for CIS-EI providers who hold a Renewal Certification and are applying again.
Personal Name
*
First Name
Last Name
Personal Email
*
example@example.com
Personal Phone Number
*
Please enter a valid phone number.
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.
Please list the highest degree you hold and your major(s) and concentration(s).
*
Please list the Vermont licenses and credentials that you hold.
*
Please submit evidence 50 hours of professional development (10 hours per year for the past 5 years). You can submit copies of your training certificates, transcripts, etc., or fill out the Professional Development Alternative Documentation Form for CIS Staff (found on the CIS-EI Certification webpage). (PDF's are preferred)
*
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Please submit your CIS-EI Individual Professional Development Plan (IPDP) (template found on the CIS-EI Certification webpage) (PDF's are preferred)
*
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Please submit a signed copy of your Supervisor’s Review of Work Evidence (template found on the CIS-EI Certification webpage). (PDF's are preferred)
*
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