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Application to become a zipLogix Certified Trainer

Please completely fill in the form below. Once filled in, click the send button and your certification instructions will be sent to the email address provided.

Select Certification Type:

Full Name:

Company:

Address:

City:

State:

Zip:

E-mail:

Phone:

Alternate Phone:

Please Check One:
	Association Staff
	Brokerage Staff
	Independant Real Estate Instructor

How did you hear about the Trainers Network?

What is your current occupation?

Briefly outline teaching experience:

Briefly outline the qualifications which demonstrate your expertise in technology in the real estate industry:

List membership in any real estate organizations and any real estate teaching designations earned:

Are you currently licensed as a real estate salesperson or broker?

	Yes
	No

If yes, which state(s):

Have you had a real estate license or any other license to practice in another profession denied, restricted, suspended or revoked or had any disciplinary action against you for any reason:

	Yes
	No

If yes, explain:

Please list which state and/or local associations libraries you use?
(Please note you are not permitted to use an association library in the practice of Real Estate unless you are a member of that association. You are permitted to have access to a library you are not a member of for training/demonstration purposes only.)

Do you currently have zipForm® Plus, zipForm® Standard, or zipTMS®?

	zipForm® Plus
	zipForm® Standard
	zipTMS®
	None

I certify that the information given in this application is true and correct to the best of my knowledge.