Institute for Objective Measurement

Application for Becoming a Diplomat

 

 

Last name:        |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|

 

First name:        |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|

 

Maiden name: |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|

 

 

Street

address:            |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|

 

|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|

 

 

City:                 |___|___|___|___|___|___|___|___|___|___|___|         State: |___|___|

 

Zip Code:         |___|___|___|___|___|  -   |___|___|___|___|

 

Country:           |___|___|___|___|___|___|___|___|___|___|___|

 

Daytime phone

number:            |___|___|___|-|___|___|___|-|___|___|___|___|-|___|___|___|___|

  Area Code                                                           Extension

 

Fax

number:            |___|___|___|-|___|___|___|-|___|___|___|___|

  Area Code                                                         

 

E-mail

address:            |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|

 

 

Education:

Name of Institution

 

|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|

 

Highest Degree Completed       |___|___|___|

 

 

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Current Employment

Present employer:         |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|

 

Employer address:        |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|

 

|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|

 

 

Present job title:                        |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|

 

Number of years held:   |___|___|

 

A brief description

of duties:           __________________________________________________________________

 

______________________________________________________________________________                       

 

 

Previous Employment:

Previous employer:       |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|

 

Previous employer address:       |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|

 

            |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|

 

 

Previous job title:                      |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|

 

A brief description

of previous duties:________________________________________________________________________

                                                                                                                                                           

_____________________________________________________________________________

 

                                                                             

Number of

years held:        |___|___|                                                                                   (Turn to the next page)

 

 

Payment:

 

”      Check in the amount of $150.00, payable to the Institute for Objective Measurement

 

”      Credit card (check one)   ______Master Card    _____ Visa  (IOM accepts no others)

 

|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|

 

Expiration date:             Month |___|___|          Year |___|___|___|___|

 

 

Signature (required) _______________________________________________________

 

 

 

Upon achieving eligibility status, I will analyze two of the following data sets and submit the required research reports (select two):

 

”     Multiple-choice test data

 

”      Survey data

 

”      Performance assessment data (three or more facets)

 

 

 

 

 

 

 

 

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Candidate Acknowledgment

 

By submitting and signing this application, I acknowledge that it will be reviewed and processed, and that the examination will be conducted in accordance with the rules and policies of the Institute of Objective Measurement.  I agree to hold harmless the members, examiners, officers, and agents of the Institute of Objective Measurement from any and all actions that they may take, or refrain from taking, pursuant to such rules and policies.

 

I certify that all information contained in this application, as well as any information that I submit in support of this application, is true and correct to the best of my knowledge and belief.  I authorize representatives of the Institute of Objective Measurement to verify the accuracy of any information contained in, or supplied in support of, this application from any person or persons having knowledge of such information contained in, and supplied in support of, this application.

 

I further recognize that admission to the certification process and any certification I have or will be granted, may be revoked at any time, if it is established that the information contained in, or supplied in support of, this application is inaccurate in any material respect; or, if I engage in any inappropriate conduct during the examination (such as giving or obtaining unauthorized information or aid). 

 

I understand that this certification process is the exclusive property of the Institute for Objective Measurement and protected by copyright law.  Because of the confidential and proprietary nature of these copyright materials, I agree not to retain, copy, disclose, or reveal any part of these examination materials, unless previously authorized in writing by the Institute for Objective Measurement.

 

 

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              Applicant’s signature (required)                                               Date

 

 

 

 

 

 

For office use only:     Member ID Number     |___|___|___|