Meditation Specialist Board Certification – MSI-BC Application Use this form to Apply for your MSI-BC Meditation Specialist Board Certification. Checklist Applicant Information Meditation Training Teaching Personal Practice References Background Submit INSTRUCTIONS Payment is required before submitting the application. Applicants must visit the Payment Page and pay for the appropriate application. The Transaction ID and Payment Date from the PayPal receipt are required to complete the application. To ensure that the application is complete, please use the checklist below. An incomplete application will not be processed and will result in a forfeiture of application fees. Use the section tabs or next button to complete all of the required information. Review and double-check all your information before clicking/tapping the submit button in the final step which will submit the application for processing. Payment Information Visit the Payment Page and complete the payment for the appropriate application fee before completing the application. You will need the Transaction ID and Payment Date that you'll receive on your receipt from PayPal. Payment Transaction ID: * Payment Date: * Checklist I am Applying for MSI-BC Board Certification. MSI-BC Initial Application Other Information You Will Need: Meditation Training Course InformationTeaching LogParticipation - Conference Call Attendance InformationReferences Meditation Specialist Class Info Date of Training * Location * Applicant Contact Information First Name * Last Name * Address Street Address * Address Line 2 City * State / Province / Region Postal Code * Country USA Phone Number * Mobile Number Email * Website List classes or one-to-one sessions that meet the certification criteria. In order to apply for the Meditation Specialist National Board Certification it is required that you meet the established criteria in continuing education. You will need to submit the your completed application by April 30th for initial certification for the two-year period. The Meditation Training criteria for the certification can be found here. Meditation Training Course Log Teaching I have taught a minimum of 150 Hours of the Core Competencies Personal Practice I have completed at least one year of personal meditation practice. References Reference #1 Full Name: * Job Title: * Email Address: * Phone Number: * Years Known: * Reference #2 Full Name: * Job Title: * Email Address: * Phone Number: * Years Known: * Reference #3 Full Name: * Job Title: * Email Address: * Phone Number: * Years Known: * Background Validation Check all items that apply Have you used, in the last three years, or do you currently use, alcohol or any drug in such a way as to impair competent and objective professional performance? Do you have any physical or mental condition that impairs competent and objective professional performance? Have you ever been adjudicated to have committed malpractice or gross or repeated negligence in your profession? Have you ever had your certificate or license to practice your profession subject to limitation, discipline, revocation or other sanction, including voluntary limitation, by a regulatory board or professional organization? Have you ever been convicted or pled guilty to or pled nolo contendere (no contest) to a felony or misdemeanor related public health or nursing? (These include but are not limited to a felony involving rape or sexual abuse of a patient or child, and actual or threatened use of a weapon.) If checked any of the above questions, please describe fully the circumstances below. Please double check all your information before submitting the form. Once you click/tap on the submit button it will submit the form for processing. Enter your full name as you would like it to appear on your Certificate I have read and agree with the Code of Professional Standards I have read and agree with the Certification/Renewal Agreement. I hereby apply for Certification as a Board Meditation Specialist by NMSCB.