WORLDWIDE ERC APPLICATION FOR (S)GMS RECERTIFICATION RENEWAL

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Oswald Bennett
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1 WORLDWIDE ERC APPLICATION FOR (S)GMS RECERTIFICATION RENEWAL INSTRUCTIONS It is not necessary to return the instructions page with your completed application. This is the form you will submit to Worldwide ERC with your renewal fee upon completion of all fifteen (1) continuing education (CE) credits. Please do not submit this application until you have completed all 1 CE credits, and not prior to four (4) months before your renewal date. We cannot accept Renewal Applications any earlier than 4 months before your expiration date. The form may be completed electronically and printed. In order to save the form electronically to your computer, you must have Adobe Acrobat Standard, Pro, or Pro Extended 7.0 or above installed on your computer. If you are using Adobe Acrobat Reader you will only be able to complete and print the form; you will NOT be able to save it electronically. Use the following sections to list global mobility related continuing education (CE) events attended during your recertification cycle that satisfies the recertification criteria. CE events earn one (1) CE credit for every hour of learning (not counting registration time, breaks, lunches, exam, etc.). All credits are granted in whole hour increments, If you are attending a large conference that includes concurrent/breakout sessions, each breakout session(s) must run at least 0 minutes in order to be counted for CE credit, and must have clearly stated objectives (see Objectives) for each break out. Please note you may not need to fill out all sections. Please see the GMS Recertification Criteria Guide online for additional information. Submission Dates Renewal applications may be submitted up to four (4) months in advance of your recertification expiration date. For example, if your recertification expiration date is 31 January 01, you may submit your completed application as early as 1 October 014. Please note that applications submitted prior to that date will be returned and you will be asked to re submit the application at the appropriate time. Applications will also be returned if it does not indicate completion of at least 1 eligible CE credits. Application will not be processed and will be returned to you if: there is no payment attached, or payment amount is incorrect; it is outside the four (4) month window to submit your application (see Submission Dates above); or total credits do not equal at least 1. Confirmation Please be advised that due to the high volume of applications, we cannot confirm receipt of individual forms. You can expect to receive a confirmation from the GMS box within four (4) weeks of your submission. Please return completed application (indicating you have finished ALL 1 CE credits) and your renewal payment to: Professional Development Department Worldwide ERC 4401 Wilson Blvd., Suite Arlington, VA 03 GMS@WorldwideERC.org PHONE: ext. FAX: Payment Information $0 USD for Worldwide ERC members $7 USD for non Worldwide ERC members Fees are subject to change without notice and are nonrefundable. To avoid multiple charges to your credit card, please do not submit your application more than one time. NOTE: A Worldwide ERC Membership is separate from your GMS designation. The GMS certification does not constitute a Worldwide ERC membership. For questions, please GMS@WorldwideERC.org or call ext..

Please do not submit this application until you have completed all 1 CE credits, and not prior to four (4) months before your renewal date.

2 (S)GMS Recertification Renewal Application APPLICANT INFORMATION First Name: Surname/Last Name: Company: Address: City: State/Province: Postal Code: Country: Telephone: E mail: Please check here if the above contains updated contact information for ALL future Worldwide ERC notices. PAYMENT INFORMATION For Office Use Only Check made payable to Worldwide ERC is enclosed for: $0 USD (Worldwide ERC members) $7 USD (non Worldwide ERC members) Charge my credit card (select one): VISA MasterCard AMEX $0 USD (Worldwide ERC members) $7 USD (non Worldwide ERC members) Card Number Name on Card Billing Address (if different from above) Exp. Date NF ID# WEB OC AUD MS CONF YR OutERC Accepted Stats Recorded On Hold Effective Date: New Expire Date: NOTE: A Worldwide ERC Membership is separate from your GMS designation. The GMS certification does not constitute a membership. Attestation I hereby verify that I have read and understand the GMS Recertification Criteria Guide, and all facts presented on this application are correct and complete. My signature (or typed name) also confirms that I have completed 1 CE credits in accordance with Worldwide ERC s CE Criteria and I understand that my application will be returned to me if incomplete. I grant permission to Worldwide ERC to make inquiries deemed necessary to verify my submitted activities for recertification. I will maintain all back up documentation (including confirmation letters, certificates of completion and/or payment verification) for a minimum of six (6) months from the date of this application, and I agree to provide any supporting documentation requested by Worldwide ERC within two weeks of said request. I understand that if I do not respond with additional information, my designation may be revoked. I further agree that manipulating any forms or falsifying any information on my application is grounds for revoking my certification. Notes: Signature My GMS expiration date is and I acknowledge that I am eligible to renew. *Please see the Submission Date section of the application for more information. If you are unsure of your expiration date, please contact the GMS department at GMS@WorldwideERC.org. Recertification Credit Summary: Non Worldwide ERC credits requested: Worldwide ERC credits requested: TOTAL Requested Hours: (This line must equal at least 1 CE credits prior to submitting your renewal application to Worldwide ERC ) Date

PAYMENT INFORMATION For Office Use Only Check made payable to Worldwide ERC is enclosed for: $0 USD (Worldwide ERC members) $7 USD (non Worldwide ERC members) Charge my credit card (select one): VISA

3 Complete this box for Conferences, Online Courses, Strategic Talent Mobility: GMS T course, and/or Learning Zone Webinars that ARE offered by Worldwide ERC Worldwide ERC Conference: 1 CE credits each Worldwide ERC Strategic Talent Mobility: GMS T course 7 CE credits Global Workforce Symposium (October) Global Workforce Summit: Talent Mobility in APAC (March) Global Workforce Summit: Talent Mobility in EMEA (February) NOTE: Conferences listed above each receive 1 CE credits. It is only necessary to list one (1) global conference you attended (even if you attended more) in order to satisfy the 1 CE credit requirement. Strategic Talent Mobility: GMS T If you have online courses, audio sessions, webinars, or Master Series credits to list, please use the following space to insert the details. EMEA and APAC Audio Sessions and Learning Zone Webinars award 1 CE credit NOTE: Live and archived LEARNING ZONE WEBINARS are approved for credit ONLY IF GMS is indicated on THE WEBINAR WEBPAGE Online Courses from the Personal Education Center earn 1 CE credits Worldwide ERC Master Series earns 3 CE credits NOTE: CRP audio sessions are NOT eligible for GMS credit. Only audio sessions from the Global Workforce Summit: Talent Mobility in APAC and Global Workforce Summit: Talent Mobility in EMEA will be accepted for GMS continuing education credit. Worldwide ERC Online Courses, Audio Sessions*, Webinars, and Master Series can be listed on this page and the next : Title: Credits: 1 3 Title: Credits: 1 3 Title: Credits: 1 3 Title: Credits: 1 3 *NOTE: CRP audio sessions are NOT eligible for GMS credit. Title: Credits: 1 3 Continue to next page

Mobility in EMEA (February) NOTE: Conferences listed above each receive 1 CE credits.

4 Title: Credits: 1 3 Title: Credits: 1 3 Title: Credits: 1 3 Title: Credits: 1 3 Title: Credits: 1 3 Title: Credits: 1 3 Title: Credits: 1 3 Title: Credits: 1 3 Title: Credits: 1 3 NOTE: CRP audio sessions are NOT eligible for GMS credit. Title: Credits: 1 3

5 Complete this box for Conferences and/or Sessions NOT offered by Worldwide ERC 8 Credits Requested: Complete this box for Conferences and/or Sessions NOT offered by Worldwide ERC 8 Credits Requested:

6 Complete this box for Conferences and/or Sessions NOT offered by Worldwide ERC 8 Credits Requested: Complete this box for Conferences and/or Sessions NOT offered by Worldwide ERC 8 Credits Requested:

7 Complete this box for Conferences and/or Sessions NOT offered by Worldwide ERC 8 Credits Requested: Complete this box for Conferences and/or Sessions NOT offered by Worldwide ERC 8 Credits Requested:

1. First MI Last Preferred Email. 2. First MI Last Preferred Email. 3. First MI Last Preferred Email. 4. First MI Last Preferred Email

1. First MI Last Preferred Email. 2. First MI Last Preferred Email. 3. First MI Last Preferred Email. 4. First MI Last Preferred Email Group Membership Application Hospital/Institution Name Address City State/Province Zip/Postal Code Contact Name Title Phone Members All new members and existing members who are renewing* their membership