Membership of the Association for Coaching UK (AC UK) is open to those individuals with an interest in coaching.

For further information on completing this form, see our membership section of the website at www.associationforcoaching.com or contact our membership team at members@associationforcoaching.com (for a postal version, please download the PDF document from the website)

Country : Argentina

Section A Personal Details

Full Name : Rosana Portelli Title: Ms Mr Other : Mrs Dr Prof Date of Birth* : 25/01/67 Address : Uruguay 460 City : Capital County : Salta Post Code : 4400

Email : info@maximosresultados.com Website (If Own Company) : Maximos Resultados.com Home Tel. No : 0054 387 4310293 Work Tel. No : 0054 387 4310293 Mobile No : Primary Language Spoken : Spanish Other Business Languages Spoken : English Occupation : CEO

Please mark () which section(s) are relevant for your service (more than one acceptable): Executive Coaching Career Coaching Personal Coaching Specialty Coaching

Sport Coaching Other:

Please mark which section is for Coaching (AC) your employment status: Membership (of )the Association relevant forRetired is open to those individuals with an interest in Coaching. Student Unemployed For further information on completing this form, see our membership section of the website at www.associationforcoaching.com or contact our membership team at Employed members@associationforcoaching.com Own Company (Self-Employed) * optional Company Name: (for a postal version, please download the PDF document from the website)
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Section A Personal Details

Section B Experience / Qualifications

Professional/Work Experience: (if applying for Associate cv or Member level please attach 1) your coaching profile / coaching
and 2) provide details of your coaching experience; either by providing a statement here or attach a log demonstrating that you have the required number of hours)

Educational Qualifications: Doctorate, BTEC, NVQ, Other)

(i.e., Degree, Masters,

Professional Memberships:

Coaching Related Qualifications/Training: Associate (please submit copies of relevant certificates if applying for
level and above)

Please state any other rationale to consider for your application :

Where did you hear about the Association for Coaching? On line

Section C Online Member Directory

Membership of the AC will allow you to promote your individual services in the online membership directory: Please submit your profile, using the online individual membership template downloaded from the website at www.associationforcoaching.com/memb/memb.htm and forward to directory@associationforcoaching.com

References
(not applicable for Affiliate grade)

A personal and a coaching professional reference is required for Associate and Member Grades; Your professional referee can be a tutor, colleaguefrom your someone who knows you in a professional capacity and has observed/benefited or client; skills, aptitude, abilities and professionalism within the field of coaching. Please note that partners and close family members are not eligible to be referees.

Personal Reference
Name : Title : Role : Email : Contact telephone numbers :

Personal and Professional References Professional Reference

Name : Title : Role : Email : Contact telephone numbers :

Section D Declaration of Membership

1.
2.

3.
4. 5. 6.

I wishmembership membership of the Association and accept that such to apply for does not confer any professional qualification. However, once accepted into membership, members may use the initials denoted in the constitution. I acknowledge that I have read a copy of the Associations Rules. I acknowledge that, dependent upon the laws of the country in which I join the Association and irrespective of the use of the term member in the documents produced by the Association, my status as a member does not necessarily confer any rights as a member by virtue of law and my rights are instead set out in the Associations Rules. I agree with the aims of the Association. I acknowledge that I have read and agree to be bound by the Associations Privacy Policy and Data Protection Guidelines. I agree with the Code of Ethics and Good Practice as published by the Association and will adhere to them.

Rosana Portelli give permission for my name and contact details (including, without limitation, web address, phone number, email address) to be published as a register, or used for AC internal marketing purposes, in paper form or on the Internet for access by members of the public. I

I Rosana Portelli agree that the Association may pass on my details, held by the Association, to its business partners, other Association for Coaching entities and any other third party organisations who the Association think may be of interest to me for the purpose of providing me with information about promotions, events, seminars and other benefits in addition to general marketing purposes.

Rosana Portelli Signed Date

05/010/2011

I declare that, to the best of my knowledge, the above information is correct, and understand that by signing this application form I have read, understood and accepted the AC guidelines pertaining to the membership criteria.

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Form number number AI1008e Form UKAI0911e

Section E Membership Levels / Fees

Grade in Sterling Fees (per annum)

Concessions for full time students

Affiliate Associate Member

43.00 (membership) + 12.00 (one time registration fee, VAT inclusive) 70.00 (membership) + 17.00 (one time registration fee, VAT inclusive) 81.00 (membership) + 22.00 (one time registration fee, VAT inclusive) 5.00

Payment by Cheque Please make your cheque payable to Association for Coaching UK and forward it to the address below. Payment by Credit/Debit Card Please call +44 (0) 845 600 4700 with your details clearly stating your name, membership level you are applying for and the relevant fee details.

Submission notes
Before you send in this application form please check that you have included: All Membership levels:

A cheque or confirmation of posting of a cheque OR Confirmation that you will be ringing our finance department on the number above

Please note that your payment must be made at the same time as sending in your application form; failure to do so may result in delays in processing your application. In the event that your application is not approved your membership fee will be refunded, however the registration fee is to cover administration costs and is non refundable. Once your payment has been processed (including cheque clearing if applicable) a receipt will be sent to you by e-mail. Associate and Member levels:

Your coaching profile / coaching cv A log demonstrating that you have the required 75+ hours (for Associate level) or 250+ hours (for Member level) combined training/experience as listed in the Membership Levels and Grading Criteria document or a statement declaring this within Section B Copies of any relevant qualifications or confirmation that you have posted them to the address below Please ensure that details are legible - especially e-mail addresses

Please SAVE your completed application and e-mail to members@associationforcoaching.com Supporting documents should be either attached to the e-mail or posted to: Membership Administration Office, Association for Coaching, 16 Linden Park Grove, Chesterfield, Derbyshire, S40 1HY, UK Please note that your application will be acknowledged within 48 hours so if you do not receive a prompt response, please do check with us that it has been received. Please ensure that the correct level of postage is used when your application is submitted. Please remember that postage is now charged by size as well as weight. www.associationforcoaching.com For any additional queries on membership please contact our Membership Team at members@associationforcoaching.com

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Form number UKAI0911e