PERSONAL INFORMATION:
Last Name:
First Name:
Address:
City:
State:
Zip:
Email:
Daytime Phone:
PLEASE PROVIDE INFORMATION IF FAITH-BASED:
Church Name:
Denomination:
Pastor's Name:
Church Address:
City:
State:
Zip:
Church Fax
Church Phone:
Church Email:
TRAINING INFORMATION:
Do you fully understand that it is necessary to be trained by a District or Regional Life In
Focus Education Coordinator, or to have completed the Training Seminar via DVD?
YES         NO
Have you viewed the Training Seminar DVDs or attended a LIVE Seminar?
By checking this box, I certify that I have completed the CORE Training either by live
instructor or by watching the training DVD.
PLEASE CHECK THE FOLLOWING TRAINING CLASSES THAT YOU HAVE ATTENDED OR VIEWED VIA TRAINING DVDS:
**ACTS (DRUG EDUCATION)**

ANGER MANAGEMENT

EMPLOYMENT DEVELOPMENT

PARENTING/MARRIAGE TRAINING
**If you are acquiring certification in the ACTS (Drug Education) program, it is
necessary to purchase & complete the ACTS Study guide and Workbook.**
Electronic Signature Requirements:
By checking this box, I certify, the pastor listed above has credentials with the United Pentecostal Church
International.  If your pastor does not have credentials with the United Pentecostal Church International, you
must provide a written recommendation from a UPCI pastor or have that pastor's information listed on this
appliction.

By checking this box, I certify that the UPCI Pastor above has approved and will endorse me for the Life In
Focus Education certification.  


By checking this box, I certify that all information submitted with this renewal is accurate and complete. I
understand that providing false information may result in revocation of my license and the imposition of
administrative penalties.
CERTIFICATION FEES:
Life In Focus Education is a self-certifying agent.  Each certification is independent of each other.  Once you
have completed the CORE Training, you need only to complete the specialized certification class(es).  ID
Badge is included in the certification cost.  The ID badge that will list your multiple (if any) certifications.

Specialized Certification Classes Available                                            Price per certification

Anger Management Implementation                                                         $20.00

Employment Development                                                                        $20.00

Parenting/Marriage Training                                                                    $20.00

ACTS         (Drug Education)                                                                    $25.00
PLEASE NOTE:  Once you have hit the submit button you will receive a confirmation page.  Once you
receive the confirmation you will be redirected to the store to purchase the Specialized Certification Classes
that you have completed. This is located in the Certification tab in the Life In Focus Store.
ONLINE APPLICATION