CEP Enrollment Form

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CEP ENROLLMENT FORM

Please type or print and complete all sections.

PLEASE CHECK ONE

New enrollment. You’ll receive an invoice for the $100 enrollment fee (stock #465-MWB). Fees for the Certified Executive Program are non-refundable and may not be credited to another student.
Re-enrollment. There’s no additional enrollment fee if you have previously taken CCUE or CEP courses.

Please indicate the last date of course activity:

PROGRAM

CCUE CFSP Specialty Undecided

PERSONAL DATA

Name:

Nickname or preferred name:

Former Name:

Sex: Female Male

CREDIT UNION DATA

Credit Union:

CUID#:

Street Address:

P.O. Box:

City: State: ZIP:

Present CU Position:

Phone Number:

E-mail Address:

Have you previously worked at another CU? Yes No
Please list:

Which of the following corresponds most closely to your present job responsibilities? (check one)
CEO/President
Senior Management
Mid-Management
Employee
Board Member

FORMAL EDUCATION

Check last year completed:

High school 9 10 11 12

College or university 13 14 15 16

Graduate school 17 18

Degree received:

AFFILIATION

Are you an employee or volunteer of an affiliated credit union, a league that is a member of CUNA, U.S. Central or its member corporates, CUNA, CUNA Mutual/Century Companies, or World Council of Credit Unions? Yes No
(Please note: Affiliation with CUNA/League is required for attendance, but limited expectations may apply. Please contact CEP staff for further instruction.)

PERSONAL DECLARATION

By checking this box I certify that all statements on this application are complete and true and are made for the purpose of enrolling in the Certified Executive Program. I have read and understand that I must meet all the requirements on page 10 to receive my designation/certification.

Signature:

100% Guarantee
CUNA Center for Professional Development is committed to providing a quality learning experience with cutting-edge topics and expert instructors. If for some reason you are not fully satisfied, contact us and we’ll provide you a full tuition refund or credit.

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