Name:
Center:
E-mail:
Phone:
Have you completed a ten-year review in your center?
Yes
No
Have you participated in a site team visit for another center?
Yes
No
Please describe your experiences as a reviewer.
What is your interest in becoming a NSTC for ACPE?
Do you have any pending complaints against you or your center?
Yes
No
If Yes, Please Explain:
Are you able to commit to attending monthly online training sessions? (or watching the recording of sessions that you are not able to attend?)
Yes
No
Are you available to complete a minimum of two reviews a year?
Yes
No
Please describe your leadership style and how you would handle a difficult review/situation.
Please list two professional references who can speak to your leadership characteristics. Please include their names, emails, and phone numbers:
Please attach your CV/Resume here:
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