Emailable Application Form

Instructions: SELECT and COPY this entire page, create an email addressed to admin@energyschool.com and PASTE clipboard contents into the body of the email. Answer all questions, add a subject line containing “Program Application” and SEND.

A $100 Deposit is required with all applications. You can send the deposit electronically via Paypal or you can send it separately by mail (to CSES, 1721 Redwood Ave., Boulder, CO 80304), or phone (303-443-9847; the message machine is secure for credit card information). Note that we need the 3-digit security code on the back of the card, in addition to the card number and expiration date.

Name:

Address:

City, State, Zip:

Home Phone:

Bus. Phone:

Fax:

Email:

Occupation & how many years experience:

Date of Birth:

How did you hear about CSES?

Training for which you are applying:

Start Date of this training:

Summarize your health education experience; specifying all professional training:

Summarize your professional experience in the health care field:

Describe your health condition & medical history, including any current medications:

Have you ever been convicted of a felony? If yes, please give details here or on a separate page, or contact us for an interview.