Complete the following form and send it with supporting documents to your Regional Public Library System headquarters when you have completed the requirements for Level One Certification.


Today's Date: ____________________

Name: __________________________________________________
             Last                                 First                            MI

Street Address: __________________________________________

City: _______________________________

State: __________

Zip Code________________

Social Security Number: _________________________________

Library Where Employed: ________________________________
(if applicable)

e-mail: _________________________________

Job Title (Current Position): ______________________________

I hereby certify that I have completed the competencies for Level One through 60 hours of instructional time and self-assessment which identifies how I meet the competencies for basic knowledge about libraries and library services and skills to carry out the competencies. I have attached a portfolio of supporting documents.

I hereby certify that the above information is true and correct to the best of my knowledge. I understand that any false statements may result in denial or revocation of the certification.



_____________________________________________
Applicant Signature

__________________
Date Signed



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