First Name:*

Middle Name/Initial:

Last Name:*

Gender:*

Email:*

Phone:*

Title / Rank:

Agency / Company:*

Address:*

City:*

State:*

Zip code:*

Country:*

Business Phone Number:*

Address:

City:

State:

Zip code:

Country:

Certification Applied for:*
---Certified Homeland Protection Professional (CHPP) Member: $495.00Certified Homeland Protection Professional (CHPP)Non-member: $595.00Certified Homeland Protection Associate (CHPA I) Member: $165.00Certified Homeland Protection Associate (CHPA I) Non-member: $265.00Certified Homeland Protection Associate (CHPA II) Member: $225.00Certified Homeland Protection Associate (CHPA II) Non-member: $325.00Certified Homeland Protection Associate (CHPA III) Member: $250.00Certified Homeland Protection Associate (CHPA III) Non-member: $350.00Certified Homeland Protection Associate (CHPA IV) Member: $450.00Certified Homeland Protection Associate (CHPA IV) Non-member: $550.00

Member ID# :

Current Status:*
Sheriff or ChiefPolice or Fire ResponderLaw EnforcementFire ServicesEmergency ManagerMilitaryHealth or Medical ResponderPrivate Sector Chief Security OfficerPrivate Sector Security DirectorPrivate Sector ResponderStudentRetiredOther

If other, please indicate:

Employer or School Name:*

Address (Street #):*

City:*

State:*

Zip Code:*

Supervisor Name or Contact for Verification:*

Contact Phone #:*

Proof of Required Course Work:

Upload PDF or JPG files or email your documents to info@globalhomeland.org
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(Limit: 5MB PDF or JPG files)

Would you like to upload a file?(jpg or pdf) yesno

Education:*
High School or GEDTechnical SchoolSome CollegeAA or ASBA or BSMastersPhD
(Please specify highest level completed)

Have you ever been convicted of a crime (or in military service convicted by a general court martial) or is there any criminal charge now pending against you?* YesNo

If the answer is "Yes", please explain.
This information will not be circulated outside the Certification Board. An affirmative answer does not necessarily mean rejection of your application. (Please omit offenses committed before your 18th birthday.)

Explanation:

Have you ever had a professional membership, license, registration, or certification denied, suspended, or revoked (other than a lack of minimum qualification or failure of examination)?* YesNo

If the answer is "Yes", please explain.
This information will not be circulated outside the Certification Board. An affirmative answer does not necessarily mean rejection of your application. (Please omit offenses committed before your 18th birthday.)

Explanation:

If separated from the U.S. Military, did you receive an honorable discharge? YesNo

$50.00 of the certification fee is a non-refundable processing fee.

(Upon successful completion of the form, please go to the on-line payment options.)

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