NBCSN Liaison Application

1. Name and Credentials: *This question is required.

2. Certificate #: *This question is required.

3. Year of Initial Certification: *This question is required.

4. Home Address: *This question is required.

5. City/State/Zip: *This question is required.

6. Home Phone: *This question is required.

7. Primary Email Address: *This question is required. This question requires a valid email address.

8. Employer: *This question is required.

9. Work Position: *This question is required.

10. Work Address: *This question is required.

11. Work City/State/Zip: *This question is required.

12. Work Phone: *This question is required.

13. Work Email Address: *This question is required.

14. Are you replacing a current liaison in your state? *This question is required.