Counselor Certification Program Debt Management Act {FIS-2303}

Counselor Certification Program - Debt Management Act This application is for the submission of a counselor certification program for DIFS approval pursuant to the Debt Management Act, 1975 PA 148, as amended, and is to be completed by counselor certification providers only. FIS 2303 (08/16) Department of Insurance and Financial Services Page 1 of 2 Name of Provider Street Address City State Website Address Federal ID # Zip Code Telephone Number with Area Code Fax Number with Area Code Program Contact Person and Title Application Contact Person and Title E-Mail Address E-Mail Address Telephone Number with Area Code Telephone Number with Area Code Please attach the following information numbered and in sequential order: 1. Outline of the proposed counselor certification program. 2. Method of instruction, whether in-person or through interactive technology, and whether open to the public or in-house for a company's employees only. 3. Information explaining how exams will be administered through proctoring services including services offered at universities and community colleges nationwide. 4. Copy of the application provided to individual/company seeking counselor certification. 5. Copy of the certification program, including any study material that is offered to those who enroll to become certified through the provider. 6. Outline of timeframe/period it takes an individual to become certified. 7. Copy of the certification exam to be provided to an individual to become certified. Indicate how often exam is revised. 8. Length of the original certification period and the process to renew. 9. A list of prerequisites, if any, required by an individual seeking certification (for example, work experience or training). 10. Copy of the certification certificate that is issued for completion of the counselor certification program. American LegalNet, Inc. www.FormsWorkFlow.com Counselor Certification Program - Debt Management Act 11. Procedures used for keeping records of attendance and completion of training and testing. Include a one page sample list of certified counselors with data fields (personal information may be redacted as appropriate). 12. A list of states in which the provider's certified counselor certification program has been approved or is pending approval. Indicate the current status for each state along with the date of approval, if applicable. 13. Detailed information pertaining to continuing Education (CE). (For Example: Does the provider offer CE itself, accept CE from other providers, or both? What is the CE requirement ­ amount of CE credits required and how often CE is required to be completed, etc.). 14. A list describing all fees charged by the provider (initial certification, recertification, CE fees, etc.). FIS 2303 (08/16) Department of Insurance and Financial Services Page 2 of 2 I verify that I am duly authorized to sign this application on behalf of my organization. I further verify that the information provided in this application and all attachments, concurrent or subsequent, are true and correct to the best of my knowledge and belief. Signature Print Name Title Date When complete, please mail to: Our delivery address is: DIFS - Consumer Finance PO Box 30220 Lansing MI 48909-7720 DIFS - Consumer Finance 530 W. Allegan Street, 7th Floor Lansing MI 48933 American LegalNet, Inc. www.FormsWorkFlow.com