All fields are mandatory unless otherwise indicated.

Name:
prefix ---MrMrsMissMsDr (medical doctor)Dr (educator)Other (details found in Additional Information box below)
first name
middle name/initial (optional)
last name
suffix (please put each suffix on a new line)

Email:
Your email address will only be used to contact you in relation to your entry on the Directory. If your email address changes, please email communication@ircmcic.org with updated details, with your name in the Subject line.

Telephone number:
Your telephone number will only be used to contact you in relation to your entry on the Directory.

Company/Organisation Name:

Country

Photograph (optional):
All photographs will be sized to 250px x 250px, therefore it would be beneficial if you could upload a photograph that is sized correctly or could be re-sized.) Where you do not upload a photograph, the system will submit a silhouette.

IRCM CIC DECLARATIONS:
I agree to abide by the IRCM CIC's industry recognised Codes of Conduct.
I agree to abide by the IRCM CIC's industry recognised Standards and Ethics.
I agree to abide by the IRCM CIC's industry recognised Core Competencies.
I agree to abide by the IRCM CIC's industry recognised Disciplinary Procedures.
I recognise the industry Ombudsman Service.

EXTERNAL VERIFICATION THROUGH ACCREDITATION/CREDENTIAL:
If you have no external verification please enter 'none' in the fields below.
If you have more than one external verification, please email communication@ircmcic.org with the additional details, putting your name on the subject line.

Professional Body Name (Accreditation/Credential Organisation):
Award (Accreditation/Credential award/grading):
Date awarded:
Is your accreditation/credential current?
---My accreditation/credential is current and valid.My accreditation/credential is not current (the expiry date is entered in the Additional Information box below).No external verification.

QUALIFICATION THROUGH TRAINING:
If you have no formal training please enter 'none' in the fields below.
If you have more than one qualification, please email communication@ircmcic.org with your additional qualification details, putting your name on the subject line.

Is your qualification through a Formal Education Body or a Private Commercial Training Organisation or a Coach/Mentor who provides the training?
---Formal Education Body (University, College, School)Private Commercial Training CompanyCoach and/or Mentor who provides trainingNo formal training
Body/Organisation Name:
The name of your Formal Education Body or Private Commercial Training Organisation or Coach/Mentor who provided your training.
Course Name:
Name of the course/workshop that you attended (as published by the training body/organisation).
Qualification:
Enter the name of your qualification, followed by the abbreviation by which it is recognised (as published by the training body/organisation). It is recognised that not every course or workshop provides a qualification and where this is the case please enter 'N/A'.
Date training started (DD/MM/YYYY):
Date qualified/completed:
The date on your qualification certificate, or where there is no qualification, the date you complete the course.

COACHING AND/OR MENTORING:
Services provided:---Coaching onlyMentoring onlyCoaching and Mentoring
Experience:
How many years have you been working in the coaching and mentoring industry?
---less than 1 year1 - 5 years6 - 10 years11 - 15 years16 - 20 years21 years or longer
Languages:
please put each language on a new line, with your home language on the first line

Specialities:
please put each speciality on a new line, with your main speciality on the first line

CONTACT ME:
Select how you want to be contacted:---EmailLink to my websiteOther
Please enter the relevant contact details:

BIOGRAPHY/DESCRIPTION:

COMPANY/ORGANISATION DETAILS:
Legal Entity Structure:
Please enter the legal entity structure as found on Wikipedia

Company Reference Number as issued by UK's Companies House, HMRC, or other relevant organisations.

Trading Start Date (DD/MM/YYYY)

Registered Office Address as registered with UK's Companies House, HMRC, or other relevant organisations:
Country
Address
City/Town
County/State
Post code/Zip code
Trading Office Address:
Country
Address
City/Town
County/State
Post code/Zip code
Insurance:
The insurance details entered here will need to be updated annually or more frequently.
It is recognised that not all countries require insurance, and therefore if you do not have insurance please enter 'none' in the following fields.
Insurance Organisation:
Insurance Type:
Certificate Number:
Date first issued (DD/MM/YYYY):
Date expires:
Logo(optional):
All images will be sized to 250px x 250px, therefore it would be beneficial if you could upload an image that is sized correctly or could be re-sized.) Where you do not upload an image, the system will not display anything.

ADDITIONAL INFORMATION:
Please enter any Additional Information relevant to your Directory entry (optional)

How did you hear about the IRCM CIC?
---ConsumerCoachMentorTraining body/organisationProfessional BodyCommercial organisationSearch engineSocial mediaAdvertOther

I confirm that I am applying to REGISTER on the IRCM CIC’s Coaches and Mentors Directory. I agree to abide by the IRCM CIC’s Terms, Conditions, and Toolkit.
click here to access the Terms, Conditions, and Toolkit.

By submitting this form, I give my authority for the information submitted on this form, as well as through other forms and communication methods to be included in detail on the IRCM CIC's Coaches and Mentors Directory; initially as LISTED and then REGISTERED once payment is confirmed.