Please identify your experience level: Newly Appointed Supervisors (Core Skill Development) Supervisor with more than one year experience Supervision Certificate Program All supervisors please fill in all of the fields below the line. Newly Appointed Supervisors please note that you will not be choosing between online or paper assessment. Newly Appointed Supervisors will receive a paper assessment when you register for the certificate course. Experienced supervisors, please select how you will participate Online assessment Paper assessment Supervisor's Name Title Agency Department Street Address City State Zip Work Phone Fax Email Authorizing Manager's Name IMPORTANT: In submission of this form, I authorize MARC to bill our agency in the amount of $500 for the cost of the initial assessment and the completion of an individual development packet. * I have read the statement to the left and agree to the required cost. Government Training Institute Mid-America Regional Council 600 Broadway, Suite 200, Kansas City, MO 64105 Phone: 816/474-4240 Fax: 816/421-7758