Paul V. Sherlock Center on Disabilities

SME Training Series Certificate Request Form

Please use this form to request an ACRE Certificate or Certificate of Completion for a mini-series. Upon receipt, the Sherlock Center will verify that you have met the requirements of the requested certificate.

Request your certificate if each of the following steps have been completed:

You have attended all required modules applicable to your certificate.
You have completed the field work assignment/s applicable to your certificate.
Your fieldwork assignments have been approved and returned to you.
You have read the ethics statement.

What you need to know:

Upon receipt of your request, the Sherlock Center will verify that you have met the requirements of the requested certificate/s.
You will be contacted by the Sherlock Center if your request is denied or additional information is needed.
Your certificate will be mailed to you at the address provided in this form.
Your name will appear on your certificate as provided in this form.

If you have questions or are experiencing difficulty with this form, contact Tracy Miller, tmiller1@ric.edu or 401-456-8072.

Request Date: *This question is required. This question requires a valid date format of MM/DD/YYYY.

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1. Certificate Requested: *This question is required.Select the ACRE Certificate option IF you have completed the full ACRE Series (full or half days) OR if you have completed each of the three topic specific series (Vocational Assessment, Job Development, and Job Retention and Coaching) within a 24 month period.

Upon receipt of your request, the Sherlock Center will verify that the attendance and fieldwork requirements are satisfactorily met prior to issuing the requested certificate/s.

What year did you start SME training? *This question is required.

2. I have read the Supported Employment Ethical Guidelines provided below. Read/download Ethical Guidelines

3. As a supported employment professional, I hereby adopt these Ethical Guidelines and agree to honor the stated principles herein. Sign below to indicate adoption.

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Signature of

CONTACT INFORMATION:
Please provide your name as you would like it to appear on your certificate. Certificates will be mailed to the address provided below.

4. First Name: *This question is required. Include middle name and/or initial with first name as desired.

5. Last Name: *This question is required.

6. Last Name used when you registered for training: *This question is required.

Current Employer:

Other Employer:

Mailing address for certificate (home or business address acceptable)

Organization Name (if providing a business address):

Other Organization:

7. Mail certificate to the organization listed above or a residential address *This question is required.

8. Provide Address 1: *This question is required.

9. Address 2:

10. City: *This question is required.

11. State: *This question is required.

12. Zip Code: *This question is required.

13. Phone: (XXX-XXX-XXXX) *This question is required. This question requires a valid number format.

14. Cell Phone: (XXX-XXX-XXXX) This question requires a valid number format.

15. Email Address: *This question is required. This question requires a valid email address.

16. Re-enter Email Address: *This question is required. This question requires a valid email address.