Date of Application:
3.1 / Course Information
1 / Course Type (Measurement, Mitigation or Both):
2 / Course Title:
3 / Description of Course:
4 / Length of Course in Hours:
5 / Number of Credits Requested:
6 / Number of Hours of Radon-Specific Material:
7 / Number of Hours of Radon-Related Material:
8 / Course Offering Type (Online, Classroom, Home Study):
9 / Intended Frequency of Course Offering:
10 / Course Fee:
11 / Number of Previous Offerings of Same Course:
Where:
12 / Current Approvals by States or Professional Organizations:
Documentation of Course Approval Included:
3.2 / Course Provider Info
13 / Name of Organization:
14 / Mailing Address:
15 / Telephone:
16 / E-mail Address
17 / Web-site Address for Course Information
Do you wish to have the AARST-NRPP website link to your website?
18 / Name of Contact Person:
Telephone:
E-Mail Address:
19 / Alternate Contact Person:
Telephone:
E-Mail Address:
20 / Description of the Organization's CE Experience:
21 / Description of Organization's Radon-Specific Training Experience:
3.3 / Course Details
22 / List the course objectives that are relevant to the needs in the current radon industry:
23 / Course Objectives' Relation to Actual Field Work Performed by Measurement and Mitigation Providers:
24 / Instructional Hours
25 / Method of Updating New Information:
26 / How will you Address Differences Between State/EPA Policy or Very Recent EPA policy or Very Recent EPA or AARST-NRPP Protocol Changes:
3.4 / Distance Learning Courses
27 / Personnel Available to Answer Student Questions:
28 / Phone Number:
Email Address:
29 / Days/Hours Available:
30 / Briefly describe your method of second-level testing:
31 / Internet Address for Course:
Login:
Password:
3.5 / Instructor Information
32 / Name of Primary Instructor:
NRPP ID Number, if applicable:
Address:
City, State, Zip
E-mail Address:
Description of Instructor's experience in the subject matter of the course:
Description of Instructor's prior teaching experience:
33 / Name of Primary Instructor:
NRPP ID Number, if applicable:
Address:
City, State, Zip
E-mail Address:
Description of Instructor's experience in the subject matter of the course:
Description of Instructor's prior teaching experience:
34 / Name of Primary Instructor:
NRPP ID Number, if applicable:
Address:
City, State, Zip
E-mail Address:
Description of Instructor's experience in the subject matter of the course:
Description of Instructor's prior teaching experience:
3.6 / Signature
By signing this application, I hereby certify that no copyright laws have been violated in the development of this course. Furthermore, I hold AARST-NRPP harmless for any deficiencies in the actual delivery of this course
Sign Here:
Print Name Signed:
Date:
3.7 / Required Submittals / Place initials by item to show that they have been submitted
36 / Completed Application
37 / Course Agenda
38 / Course Outline
39 / Instruction Materials
40 / Course Evaluation by Students (include second level testing method described on line 30, if this is a distance based course
41 / Evaluation of Student Proficiency
42 / Certificate of Completion
43 / Resume(s) for Primary Instructor(s)
44 / Payment of Application Fee / $
Acceptable form of payment: Check (made payable to AARST-NRPP) or Credit Card
Payment Method
Please include a check or money order made payable to “AARST-NRPP”
Indicate Check Number Here: ______
OR complete thefollowing:
MasterCardVISAAmericanExpress
Credit Card#:______
ExpirationDate:______
Name on theCard:______
Billing Address: ______
City, State and Zip: ______
Authorized Signature: ______
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