Name:____________________________________________________________________ Date :_____________

Mailing Address:______________________________________________________________________________

City:____________________________________ State:_____________ Zip:____________________________

Phone:__________________________________ Fax:________________________________________________

Email Address:________________________________________________________________________________

School or Educational Program Attended for Grief Counseling:______________________________________

Date of Completion:_________________________________ Number of hours of instruction:______________

Applicants must submit one of the following: 1) a copy of their certificate of completion, or 2) an official letter by the school, educational program, or instructor verifying successful completion of the program and the number of contact hours of the educational program. Note: if the certificate of completion does not have the number of contact hours detailed on it, then it is necessary to submit an official letter from the school, program or instructor verifying the number of hours or college credits earned.

For translation purposes, the AAGC uses the following conversion: 50 minutes = 1 contact hour. 1 semester unit of college credit = 15 contact hours.

For Applicants Applying with Education Hours from various courses, seminars, etc.

Applicants must submit to the American Academy of Grief Counseling photocopies of all education certificates or transcripts, verifying attendance and completion of the educational programs, seminars, courses, etc. The AAGC reserves the right to contact any providers of such programs and verify completion/attendance by the applicant.

For Applicants applying for Certification by Evidence of University/College Degree and Education Hours

University/College that granted Degree:___________________________________________________________

State:_________________________________ City:__________________________________________________

Degree Granted:_______________________________________________________________________________

Date Degree was Conferred: ____________________________________________________________________

For applicants applying for Certification by Funeral Director or Clergy License

Employer:____________________________________________________________________________________

If self employed, name of business:_______________________________________________________________

City:__________________________________ State:__________________ Zip:_________________________

Phone:______________________________________ Fax:____________________________________________

Funeral Directors: State you hold license:________________________ License #_______________________

Date of Expiration:__________________________

Clergy: Seminary or Education program graduated from:___________________________________________

State you practice or hold license:_______________________ License #: ______________________

Applicants must submit to the American Academy of Grief Counseling photocopies of all education certificates or transcripts, verifying attendance and completion of the educational programs, seminars, courses, etc. The AAGC reserves the right to contact any providers of such programs and verify completion/attendance by the applicant.

Method of Payment- Application fee for 3 year term of certification is $ 150.00

_____ Check

_____ Money Order

_____ Credit Card _____ Visa _____ MC

Card Number:____________________________________________________ Expiration:_________________

Name on Card:___________________________________________________ Signature:___________________

_____________________________________________________________________________________________

I, the undersigned, verify that this application is complete, and to the best of my knowledge, all information provided is factual and true. I understand that failure to provided the needed information and required documentation could likely lead to delays in the processing of this application. I further understand that if any information supplied on this application is false, that I will be denied consideration for certification. I further understand that if at any time it is discovered that I have made false or untrue statements on this application, or misrepresented myself, or have provided fraudulent documentation to the AAGC, that the AAGC may rescind my certification and fellowship status.

Agreed:

______________________________________________________________ Date:________________________

Signature