Athletic Trainer Form 1 - Application For Certification - 2016 Page 2
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State the name of any National Association by which you were certified and the date of the certification.
Name of Association: ____________________________________________________________ Date of Certification: _______ / _______ / _______
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Please print clearly giving an accurate record of your educational preparation below. Be sure to complete all information for all colleges/universities
attended and degrees received. Attach additional sheets if necessary.
High School/Secondary School
Name of School: ___________________________________________________________________________________________________________
City: ____________________________________ State/Province: ____________________________ Country: ______________________________
Number of years attended: __________________________
Attendance from: ________ / ________ to ________ / ________
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yr.
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yr.
Graduation date: ________ / ________
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yr.
Professional School(s)
Name of College/University: __________________________________________________________________________________________________
City: ____________________________________ State/Province: ____________________________ Country: ______________________________
Major/Concentration: ________________________________________________________________________________________________________
Number of years attended: __________________________
Attendance from: ________ / ________ to ________ / ________
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yr.
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yr.
Title of Degree/Diploma/Certificate awarded (in the original language): _________________________________________________________________
Name of College/University: __________________________________________________________________________________________________
City: ____________________________________ State/Province: ____________________________ Country: ______________________________
Major/Concentration: ________________________________________________________________________________________________________
Number of years attended: __________________________
Attendance from: ________ / ________ to ________ / ________
mo.
yr.
mo.
yr.
Title of Degree/Diploma/Certificate awarded (in the original language): _________________________________________________________________
Name of College/University: __________________________________________________________________________________________________
City: ____________________________________ State/Province: ____________________________ Country: ______________________________
Major/Concentration: ________________________________________________________________________________________________________
Number of years attended: __________________________
Attendance from: ________ / ________ to ________ / ________
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yr.
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yr.
Title of Degree/Diploma/Certificate awarded (in the original language): _________________________________________________________________
Practicum Experience
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Name(s) and Location(s) of the site(s) of your practicum or supervised
Dates of Attendance
Supervisor
clinical experience.
From
To
Athletic Trainer Form 1, Page 2 of 4, Rev. 6/16
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