Location of IIT Start date (MONTH) Start date (DAY) Start date (YEAR)

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1 2011 International Intensive Training (IIT) Program Application The Center for Nonviolent Communication 5600 San Francisco Road NE, Suite A Albuquerque, NM U.S.A. Tel: (toll free ) Fax: iit@cnvc.org Location of IIT Start date (MONTH) Start date (DAY) Start date (YEAR) 2. Last Name (Surname or Family Name) First Name (Given Name) Middle Initial 3. Check one: Male Female 4. Date of birth (MM/DD/YY): 5. Address: 6. Mailing address. Please include street address, postal code, and country: 7. Telephone numbers in international format. (Note: Country Code for USA and Canada is 1): Home: + (country code) (area code) (phone number) Work: + (country code) (area code) (phone number) Cell: + (country code) (area code) (phone number) Fax: + (country code) (area code) (phone number) 8. Please indicate the language(s) that you speak and understand fluently: English Arabic German Spanish French Mandarin Japanese Italian Other: 9. CNVC Affiliation (Check all that apply): Are you a CNVC Certified Trainer? Yes, since No Are you a CNVC Registered Certification Candidate? Yes* No * The certification process Assessor s name is: Yes* No Have you attended an IIT before? * We may place you in a standby position to provide an opportunity for those who have never attended an IIT. Page 1 of 5

2 10. Would you like assistance with getting a travel visa in order to attend the IIT? No *Yes * If yes, please provide the following: Passport # Country that issued passport Date of issue Date of expiration Place of birth Date of birth 11. Occupation 12. How did you learn about this training program? 13. Please list any prior exposure to Nonviolent Communication, including materials, trainings, connections, etc.: 14. How do you intend to apply this training? 15. What needs are you hoping to meet by attending this IIT? Page 2 of 5

3 16. What is your meal preference? (Please pick only one) Vegetarian Non-Vegetarian 17. Do you have any conditions, allergies, personal needs, or requests that may require special attention? (Check one): No Yes: (please explain) Please note: If your request is diet-related, CNVC will try and see that accommodations are made, but please be prepared for the possibility of providing your own meals and/or dietary supplements. Accommodations for specific requests may be somewhat limited. 18. Please specify your room preference from the list below. Please do not leave any part of this question blank or incomplete: Your enrollment will not be complete without this information. CNVC tries to accommodate requests, but does not guarantee availability of any specific room type or roommate. (I) Requested room type (see Basic Information Sheet): Cost: (II) If this room type is not available, I do NOT want CNVC to enroll me I want CNVC to enroll me anyway, as long as I am assigned a room of equal or lesser cost. I want CNVC to enroll me anyway. If the only option available is a room of higher cost, I agree to pay the higher charge. (III) Do you have a specific roommate request? No Yes, I would like to be my roommate. 19. Payment Agreements: (Check all that apply): I am enclosing payment as specified in #21 of this application (minimum initial payment is the $100 nonrefundable application fee). If the enclosed amount is less than the full amount, I agree to pay the balance at least 1 calendar month before the start of the IIT. (Applications sent within four weeks of the start of the IIT must be accompanied by full payment.) I am not enclosing any payment. I am: enclosing a Tuition Reduction Request Form (*). I understand that my application will only be considered if received by CNVC at least THREE (3) calendar months before the start of the IIT. I understand that my request may not be funded and that upon receipt of the Tuition Reduction Committee s decision, I will have the choice to withdraw or confirm my enrollment. I agree to pay any remaining balance within 1 calendar month prior to the start of the IIT, if you confirm enrollment. *To obtain a Tuition Reduction Request Form, call or CNVC, or download the form from our website: in the process of applying for travel visa to the United States from a country not included in the US Visa Waiver Program (*) or the equivalent for the country in which the IIT is held. I understand that if CNVC IIT Administration has not received an update and payment from me by 3 weeks prior to the start of the IIT, they may cancel my enrollment. * Visa Waiver Program Countries: Page 3 of 5

4 20. Would you be willing to contribute to our CNVC Training Fund to make it possible for others who are less affluent to participate in an IIT? Amount of donation: 21. Payment Method: I am enclosing a check, or money order. Amount: I wish to pay via WIRE TRANSFER and request CNVC s Bank Information to process this payment. I authorize CNVC to charge my credit card as indicated below. ****If you are only paying the $100 nonrefundable application fee at this time, please check one of the following: I wish to receive the 10% discount off tuition, and authorize CNVC to charge the same credit card for remaining balance 3 calendar months before the start of the IIT. I authorize CNVC to charge the same credit card for remaining balance 1 calendar month before the start of the IIT. I do not authorize CNVC to charge the same credit card for remaining balance I will contact CNVC and provide a different payment method by the due date 1 calendar month before the start of the IIT. FOR SAFETY REASONS, PLEASE DO NOT CREDIT CARD INFORMATION. IF PAYING BY CREDIT CARD, PLEASE CALL/FAX IN YOUR CREDIT CARD INFORMATION SEPARATELY OR SEND YOUR APPLICATION BY POSTAL SERVICE OR FAX. Visa MasterCard American Express Discover Amount Credit Card No. Exp. Date Cardholder s Signature PRINT Cardholder s Name Page 4 of 5

5 22. Agreements between The Center for Nonviolent Communication and IIT Participants: Please carefully read the Program Terms and Conditions set forth below and acknowledge your acceptance by initialing after each paragraph in the space assigned. Admission to the International Intensive Training (IIT) program is by application only and some applicants may not be accepted into the IIT. Please contact the IIT Department prior to signing the contract if you have questions about the Program Terms and Conditions. More information about the needs we are aiming to meet through this agreement is described in FAQ: A. I hereby affirm my understanding and agreement that my participation in The Center for Nonviolent Communication International Intensive Training Program does NOT certify me as an authorized instructor or trainer for or by The Center for Nonviolent Communication ( CNVC ). If I share NVC, I agree that I will not represent myself as being certified or authorized as such. I also agree to follow the Guidelines for Sharing NVC for Those Who Are Not CNVC Certified Trainers, found on the website: unless/until I become a CNVC Certified Trainer. Initials: B. I acknowledge and agree that the training materials are protected by copyright owned by or licensed to CNVC and I agree that no copies of these materials, audio or visual recordings of CNVC sessions may be made. Initials: C. I understand that CNVC may at any time record training sessions or activities. I give permission to CNVC to use, without charge, limitation, obligation or liability, my likeness on any recording(s) made by CNVC during the training period and I release CNVC and its representatives from any liability arising in connection with any such use of recording(s). I understand recordings to include audio recordings, video recordings, movie recordings and still photographs. Initials: D. I understand that I am responsible for my own behavior at all times while participating in the CNVC training program. I understand that the program may offer a variety of activities that may be mentally or emotionally challenging and engaging. The level of my participation in any of these activities is at all times completely my choice. I am aware that I may cease my participation at any time. In the event of an emergency, I give CNVC permission to call an ambulance or physician. Initials: E. I understand that the IIT is a closed event and that only IIT participants may partake in the sessions. I agree that I will not bring others to the IIT venue unless they are enrolled participants. (This does not apply to the public event Giraffes Around The World, where visitors are welcome and encouraged.) Initials: F. In the event that the IIT for which this is an application does not take place, I agree that CNVC shall have no obligation to compensate me for costs incurred above the IIT Tuition. Further, I understand that refunds of prepayments made to CNVC shall be handled according to the IIT Cancellations and Refunds policy which is set forth on the CNVC website at Initials: G. I have entered into this agreement knowingly and voluntarily on the basis of my own information and not in reliance upon representations of CNVC or its representatives. I have read, understand and agree to abide by these Terms and Conditions. Initials: Applicant s Signature Date 23. Send this form with your payment to: CNVC / IIT Dept 5600 San Francisco Road NE, suite A OR Fax: Albuquerque, NM iit@cnvc.org (No credit card info, please.) CNVC will acknowledge receiving your application within 5 business days. If you did not receive a response within that timeframe, or have questions or inquiries, please contact us as follows: iit@cnvc.org Phone: (Toll Free: ) Website: Fax: Page 5 of 5