KCRA VOLUNTARY CERTIFICATION PROGRAM

GRANDFATHER APPLICATION

(Grandfather period valid until December 31, 2004)

First Name ____________________________Last Name_________________________

Address ________________________________________________________________

City __________________________________ State________________ZIP_________

List all current certifications, if any: _________________________________________

Reporting Method (Circle One) Stenotype Pen

Employment Type: Official Freelance Captioning/CART Other _______________

PLEASE SUBMIT THE FOLLOWING WITH YOUR APPLICATION:

Check or Money Order payable to KCRA in the amount of $30.00

Copies of any current state or national certifications

Copy of current Kentucky Notary Public certificate

If you are an official reporter not required to be a Notary Public, please sign the following waiver:

WAIVER: I hereby certify that my current reporting position does not require me to be a Kentucky Notary Public:

Signature: ______________________________________________

Please submit your application and all required documentation to KCRA offices at the address below. Incomplete applications will be returned to you.

I hereby certify that the information submitted is accurate and truthful, and I further certify that I will abide by all rules, policies and procedures governing this Voluntary Certification Program and that of the

Kentucky Court Reporters Association.

Signature ______________________________________Date ___________

KCRA, P.O. Box 4463, Midway, Kentucky 40347 (859) 846-4847

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