American Society for Trainers and Coaches

Section A — Applicant Details

Legal Full Name (as on ID) *

Preferred Professional Name

Date of Birth (MM/DD/YYYY) *

Country of Citizenship *

Email Address *

Telephone (with country code) *

Mailing Address — Street *

City / State or Province *

ZIP / Postal Code *

Country of Residence *

Current ASTC Membership Number (if any)

LinkedIn or Professional Profile URL

Government Photo ID Type *

ID Number (last four characters only) *

Section B — Designation Applied For

Select Designation *

ASTC-APC

Associate Professional Coach

ASTC-PC

Professional Coach

ASTC-MC

Master Coach

Application Type *

New application

Upgrade from:

Reinstatement

Route *

Standard route

Recognition of Prior Certification (complete Section D)

Section C — Education and Qualifications

Qualification / Certification	Awarding Institution	Country	Year Awarded

Section D — Professional Experience

Organization	Role / Title	Dates (MM/YYYY)	Principal Coach Responsibilities

Total years of Coach experience *

Primary Coach domains *

Delivery modes *

Section E — Coach Delivery Record (Preceding 12 months)

Summarize below and provide the full log in Schedule B. Minimum requirement: 60 hours (APT); 100 hours (PT, MT).

Program Title	Client / Employer	Dates	Contact Hours	Participants

Total Contact Hours Claimed: 0

Section F — Professional References

Note: APC requires no reference. PC requires one reference. MC require two references (including one client or mentee).

Reference 1

Name and Title

Organization

Email

Relationship to Applicant

Reference 2

Name and Title

Organization

Email

Relationship to Applicant

Section G — Declarations

I declare, under penalty of the ASTC Code of Ethics and any applicable law, that:

All information in this application and its schedules is true, accurate, and complete, and all evidence submitted is my own work or accurately attributed.
I authorize ASTC to verify any statement made, to contact the referees and organizations named, and to request further evidence.
I have read and agree to be bound by the ASTC Code of Ethics and Professional Standards.
I understand that fees for application and assessment are payable for the assessment process itself and are not contingent on a successful outcome.
I understand that material misrepresentation will result in rejection, and that if discovered after award will result in revocation and publication of that fact on the credential registry.
I consent to the processing and retention of my data as described in Section 1.6 of this Handbook, and to the publication of my name, designation, and credential status on the public registry.

Disclose any prior professional sanction, license revocation, credential withdrawal, or pending ethics proceeding in any jurisdiction (if none, write 'N/A'):

Printed Name *

Date (MM/DD/YYYY) *

Applicant Digital Signature / Initials *

I agree to all the terms and declarations stated above.

Coach Accreditation Application Form