TTT Facilitator Trainer Information

TTT Licensee Organization*

Location*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Name of Licensee Representative Submitting this form*

First NameLast Name

Email of Representative Submitting this form*

example@example.com

Phone Number

Area CodePhone Number

MRT TTT Licensee agrees that in order for the person named below on this form to be trained as an MRT Facilitator Trainer, Licensee’s staff member must have been certified by CCI as an MRT facilitator.

This form must be submitted at least 30 days prior to the first observation of the TTT certification process.

Name of Prospective MRT Facilitator Trainer*

First NameLast Name

Title of Prospective MRT Facilitator Trainer*

Phone Number of Prospective MRT Facilitator Trainer*

Area CodePhone Number

Email of Prospective MRT Facilitator Trainer*

example@example.com

The member of MRT TTT Licensee’s staff named above who receives certification as an MRT Facilitator Trainer, may conduct an unlimited number of MRT Facilitator trainings only while employed by Licensee and solely for Licensee’s staff. Training may not be conducted for any third party or person employed by a third-party agency.

Licensee and Licensee staff acknowledge that ownership of all copyrighted materials will be retained by original copyright holder. Licensee and all Licensee staff agree not to disclose any proprietary information and confidential information of CCI regardless of media source that is subject to copyright held by CCI, Eagle Wing Books, or deemed by CCI to be a trade secret without the express written permission of a CCI representative.

Submission of this form serves as full consent to these statements.