Consultant Application Section 1. Consultant Criteria

SCCM Member (required for all applicants)

To become an FCCS: OB consultant, an applicant must fulfill ONE of these two eligibility pathways. Please select one 1. Current FCCS consultants

Current FCCS consultants may also serve as consultants for FCCS: OB courses.

Type Information (English Only) (* denotes required field).

2. Current FCCS: OB directors

Teach/Direct in at least two approved FCCS: OB courses in the previous two years

Submit the FCCS: OB Course Consultant Letter of Recommendation

Section 1. Contact Information

*Last Name: *First Name: Middle Initial:

*Credential(s): *SCCM Member No.:

*Contact Info: Institution:

*Street Address: *City:

State/Province: Zip Code: *Country:

*Telephone: Fax: *Email:

Section 2. Course Information *FCCS: OB courses you directed:

*Date: *Course Site:

*Date: *Course Site:

Section 3. Consultant Information

*Would you act as a consultant for out-of-state or international courses? Yes No

*Letter of recommendation provided by:

*Applicant Signature

(Name of active FCCS or FCCS: OB Consultant)

I certify that the above information is true and accurate. Typing name in the signature space provided shall serve as lawful signature as if signed by hand in person.

ALLOW 2-4 WEEKS FOR PROCESSING APPLICATION