CM Application Form: I. Personal Information

CM APPLICATION FORM
Congratulations on choosing to pursue Certified Manager (CM) certification. This application

determines your eligibility to take the CM certification exams by assessing points in two areas:
education and experience. Applications are reviewed on a continuous basis and applicants are
notified of eligibility by Mail or Telephone.
Instruction
1. Fill in all application blanks in block letters
2. Complete all applications in two copies
3. Submit the following along with the application
a. supporting documents outlines in section II to verify education and experience
(original with two copies)
b. Sealed & signed one Employer's Reference Statement (Section VI)
c. Signed two copies of ICPM's Code of Ethics (Section V)
d. 250 Birr application fee
4. Mail or hand deliver the application, documentation, and application payment to Jethro-lmi
I. Personal Information
Last Name /Grand Father Name/ First Name/ Your Name/ Mid Name /Father Name/
___________________________ / ___________________________ / _____________________
(Title, Mr, Mrs, Ms, Dr--): ______________ Male Female
Date of Birth: /MM/______/DD/_____/YY/_______ (G.C) Nationality: _______________________
Region: ____________________ Woreda/Sub City: ____________________ Kebele/H.No:
_____________ Telephone: Home: ____________________ Cell Phone:_________________
P.O.Box:__________________ E:mail:___________________ Fax: ________________________
Current Position (Job title): ________________________________________________________

Institutional Affiliation (Employer): __________________________________________________
How did you hear about the CM program?

Newspaper Ad Internet Search Referral
Jethro-lmi/ICPM website Other _______________ (Please specify)
Name, as you wish it to appear on your certificate:
__________________________/__________________________/__________________________
Tele: +251 118 294 201/02, Cell: +251 923 517 697/98
E-mail: info@jethrolmi.com / tc@jethrolmi.com / www.jethrolmi.com
P.O.Box 43573 Addis Ababa, Ethiopia
II. Eligibility
To be eligible for CM certification, an applicant must document a total of 10 points and meet the minimum
point requirement for each of the eligibility criteria: education and experience. Applicants with less than 10
points and who meet the minimum point requirement for one of the eligibility criteria (education or
experience) may apply as an Associate Certified Manager (ACM). An ACM can obtain full CM status when
documentation is provided to Jethro-lmi that the deficient eligibility criterion has been met.
A. Education Points (Account for 3 min to 6 max education points)

Document the points reported below with: (1) a photocopy of your highest degree or equivalent
attained, and/or (2) a collage/university transcript, and/or (3) letter(s)/certificate(s) of management
training attended.
Record and document no more than 6 points in this section Points

1. High school education (1 point)
School Name ______________________________ Dates______________ ______
2. College (record highest degree attained: Dip=2pts, Deg=4pts, Master/PHD=5pts)
Collage Name ____________________________________ Degree________
Location ______________________________ Date Awarded: ____________ ______
3. Management Training (40 hrs=1pt, CM Program=3pts, Other Certifications=1pts)
Course______________________________ Provider___________________
Location_____________________________ Dates_________ Hrs ________ ______
Course______________________________ Provider___________________
Location_____________________________ Dates_________ Hrs ________ ______
Sub-total Education Points _____
B. Experience Points (Account for 4 to 7 experience points)

Document the points reported using the Employer's Reference Statement provided. Reference
Statements can be submitted directly to Jethro-lmi.
Record and Document no more than 7 points in this section Points

1. Management: manager, supervisor, group/team leader (1 pt/ye X ___ yrs)
Employer: _________________________________ Dates ___________
Location: __________________________ Title: ____________________ _______
Employer: _________________________________ Dates ___________
Location: __________________________ Title: ____________________ _______
2. Non-Management: business, sales, retail, manufacturing, educator, etc (0.5pts/yr X yrs)
Employer: _________________________________ Dates ___________
Location: __________________________ Title: ____________________ _______
Employer: _________________________________ Dates ____________
Location: __________________________ Title: _____________________ _______
Tele: +251 118 294 201/02, Cell: +251 923 517 697/98
3. Military Service: (manager/group leader=1 pt/yr x __yrs; non-manager= 0.5 pts/yr x __yrs)
Branch of Service: ___________________ Rank: ___________ Dates: _________ _______
4. Other leadership/management experience (non-work related- ICPM will assign points

____________________________________________________________________
________________________________________________________________________
_____________________________________________________
Sub-total Experience points _____
Total Education & Experience Points _____
III. Payment Information
Training Cost
Tuition fee and Installment Type Amount Charge in USD

1. One Payment At registration $$ 1,800
1,490
2. Two Installment At registration $$ 950
1,000
At the End of 1st Module or $$ 950
550
(At the start of 2nd Module)
3. Triple Installment At registration $ 1,000
$ 650
At the End of 1st Module or $ 300
$ 650
At the End of 2nd Module or $$ 650
300
4. Application fee Taking the Application $$50
20
Finical Source
Government Organization (Sponsor letter must be attached)
Business Organization/Company (Sponsor letter must be attached)
Non-Governmental Organization (Sponsor letter must be attached)
Self-sponsor
Tele: +251 118 294 201/02, Cell: +251 923 517 697/98
IV.Application Checklist
Before submitting your application, please be sure the following items are included
 Application form with all sections completed
 documentation to verify education- copies of highest degree and/or training certificate
 documentation to verify experience- Signed Reference Statement
 Sponsorship letter whose financial source is organization
 Signed ICPM's Code of Ethics
V. ICPM's Code of Ethics

In keeping with the mission of the Institute of Certified Professional Managers, to increase the
competency and professionalism of managers worldwide, I have read and agree to abide by the
ICPM Code of Ethics that follows. In addition, I attest that all information provided on this
application is true and verifiable, and I understand that the payment of an annual recertification
fee and the completion of ongoing professional development are required to maintain current
certification status.
ICPM Code of Ethics

 I will recognize that management is a call to service with responsibilities to my direct
reports, associates, supervisors, employer, community, nation and world.
 I will maintain honest relations with customers, suppliers, management and employees.
 I will recognize that, as a leader, my own pattern of work and life will exert more
influence than what I say or write.
 I will give the same consideration to the rights and interests of others that I ask for
myself.
 I will consider and look for value in the ideas and opinions of others.
 I will regard my role as a manager as an obligation to help others achieve personal and
professional fulfillment.
 I will set reasonable performance goals for myself and for my direct reports and balance
the interests of management and employees during challenging times.
 I will promote and practice the management principles and methods I have learned in
achieving management certification.
 I will report and encourage others to report unethical business practices to appropriate
authorities.
 I will discourage and confront any inappropriate behavior observed or reported to me
Applicant's Signature: ________________________________ Date: ________________
Tele: +251 118 294 201/02, Cell: +251 923 517 697/98
VI. Employer's Reference Statement
The applicant listed below has applied to the Institute of Certified Professional Managers (ICPM) to obtain
Certified Manager (CM) certification. ICPM is an educational and business center of James Madison
University. Certified Managers maintain high performance standards in management practice and make a
commitment to continuing professional development. All applicants are reviewed for eligibility before taking
3 challenging CM certification exams. You are being asked to support the candidacy of this applicant by
verifying their employment and workplace responsibilities (managerial or non-managerial). The completed
reference statement may be returned directly to the authorized training partner in Ethiopia (Jethro-lmi)
To be completed by Applicant
Applicant's Name: ____________________________ Position: _______________________
Employer: ___________________________________________________________________
To be completed by Employer
Name of Employer's Representative _____________________________ Title ___________
Dates of Applicant's Employment _______________________________________________
Does/Did Applicant has management responsibility: Yes No
If yes, details those responsibilities: ___________________________________________
_______________________________________________________________________________________
_________
Employer's Signature: ______________________ Date _____________________________
Business Phone: ____________________________ Email: ____________________________
Certified Manager (CM) certification is an independent verification of management competency that is evidenced by the globally
recognized CMTM professional credential. ICPM has a 37 year history of certifying managers in all industries. Jethro Leadership &
Management Institute (Jethro-lmi) is an authorized partner to provide CM in Ethiopia.
Tele: +251 118 294 201/02, Cell: +251 923 517 697/98

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CM APPLICATION FORM

Congratulations on choosing to pursue Certified Manager (CM) certification. This application

Current Position (Job title): ________________________________________________________

How did you hear about the CM program?

Name, as you wish it to appear on your certificate:

A. Education Points (Account for 3 min to 6 max education points)

Record and document no more than 6 points in this section Points

Sub-total Education Points _____

B. Experience Points (Account for 4 to 7 experience points)

Record and Document no more than 7 points in this section Points

4. Other leadership/management experience (non-work related- ICPM will assign points

Total Education & Experience Points _____

III. Payment Information

Tuition fee and Installment Type Amount Charge in USD

Business Organization/Company (Sponsor letter must be attached)

Non-Governmental Organization (Sponsor letter must be attached)

V. ICPM's Code of Ethics

ICPM Code of Ethics

Applicant's Signature: ________________________________ Date: ________________

Business Phone: ____________________________ Email: ____________________________

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Applicant's Signature: ________________ Date:

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