First Name: Last Name:

Middle Initial:

ACSM ID #:

Business Address:

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Postal Code: Country:

Business Phone: E-mail:

Please check all certifications/registrations you have attained that are currently valid:

ACSM certified Personal Trainer^SM
ACSM/NCPAD Certified Inclusive Fitness Trainer ®
ACSM Health/Fitness Instructor ®
ACSM Exercise Specialist ®
ACSM Registered Clinical Exercise Physiologist ®
ACSM Exercise Test Technologist^SM
ACSM Group Exercise Leader^SM
ACSM Health/Fitness Director ®
ACSM Program Director^SM

I state that all information contained on this form is true and I give ACSM the right to verify my credentials. By signing above, I acknowledge that this information will be made available to the public. I understand that I will be disqualified from participating in the ACSM ProFinder if I have given false or misleading information and if my credential becomes invalid (recertification has not been completed). I also understand that ACSM has the right to revoke my participation in the ACSM ProFinder for any reason whatsoever.