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Clinical Exercise Specialist or Lifestyle and WeightManagement Consultant Exam Registration Form

In order to take the Lifestyle & Management Consultant Certification exam, you must hold a current ACE Personal Trainer, Group Fitness Instructor or Clinical ExerciseSpecialist Certification; or a NCCA-accredited certification; or hold a four-year (bachelors) degree in Exercise Science, Nutrition or related field. Candidates holding degrees inNutrition or Nursing may need to submit documentation supporting completion of Exercise Science-related coursework.

In order to take the Clinical Exercise SpecialistCertification exam, you must have 300 hours of work experience designing and implementing exercise programs forapparently healthy individuals and/or high-risk individuals, as documented by a qualified professional. You must also have a four-year (bachelor's) degree in an ExerciseScience or related field; or a current ACE Personal Trainer certification; or a NCCA-accredited certification.

Please print, complete, sign and date the Registration Form and the Applicant Documentation Form and mail to ACE with your registration fee.

Registration forms must be postmarked or time stamped no later than 45 days pr ior to the exam date.

ACE Exam Registration4851 Paramount Drive, San Diego, CA 92123Fax: 858-279-8064

First Name: Last Name: MI:

Birthdate: SSN: Male Female

Address: City:

State/Province: Zip/Postal Code: Country:

Day Phone: Evening Phone: Email:

Please indicate which test you are registering for:

CES Exam LWMC Exam Exam Date:

Please indicate the following if applicable:

Retake CES Exam Reschedule CES Exam Previous Exam Date: Previous Location

Retake LWMC Exam Reschedule LWMC Exam Previous Exam Date: Previous Location

Do you Require special accommodations for the exam?[ __ ] Yes * [ __] No

If you have a special testing need, we will try our best to accommodate you. If your special need is not listed here, please write or call ACE Exam Registration. Specialrequests regarding the following must be received by ACE or postmarked at least 60 days prior to the exam date. Any requests submitted without supporting documentationwill be rejected. Candidates will be registered for the exam, but not approved for accommodations. A $50 reschedule fee will be charged to the candidate to reschedule

Religious Obligations. If the ACE certification exam is held on a day that conflicts with your religious obligations, ACE will try to arrange a special exam day foryou. Please include a letter from your clergy to ACE documenting your need for a special exam day.

Limited English Proficiency. At this time, ACE certification exams are offered only in English and Spanish. If English is not your first language and you wish tohave additional time to take the exam, submit a copy of your birth certificate or passport to ACE with your registration.

Disabled Candidates: Special arrangements, at no charge, can be made if you have a visual, sensory, physical or other disability that prevents you from taking

the exam under standard conditions. According to the Americans with Disabilities Act (ADA), documentation of the disability must be made by a professional,qualified to diagnose the disability. Written requests and completed registration information from disabled candidates must include a description of theaccommodation requested. ACE reserves the right to determine if the requested accommodation is reasonable. Requests for special accommodations must bepostmarked by the ADA request deadline and submitted to ACE.

Other Requests: Special arrangements, at no charge, can be made if you have other special requests that are not listed above. Documentation of this specialneed, made by a professional qualified to make a diagnosis must be submitted with your request. ACE reserves the right to determine if the requestedaccommodation is reasonable. Requests for special accommodations must be postmarked by the ADA request deadline and submitted to ACE.

Accommodation Request: International Military Personnel and Dependents (DANTES)

Religious Obligations Limited English Proficiency Disabled Candidates Other: ______________________

[ _ ] I've enclosed a check or money order made payable to: ACE Certification Exam Total Fee Enclosed: $

[ _ ] Please bill my credit card: [ _ ] VISA [ _ ] MasterCard [ _ ] American Express Charge Amt. $ Card Holder:

Card #: Expiration Date: Signature:

AFFIRMATIONThis is to affirm that the information contained in my registration form is true, complete, and correct to the best of my knowledge. I accept the conditions set forth in the ACEcertification guide concerning the administration of this test, the reporting of test scores, the certification process, and policies and ACE Professional Practices and DisciplinaryProcedures. I agree to release to ACE any information relevant to my certification and recertification, including proof of current CPR certification. I further understand that ifany information is later determined to be false, ACE reserves the r ight to revoke any certification that has been granted on the basis hereof. I agree with, accept, and willadhere to the ACE Code of Ethics and ACE Professional Practices and Disciplinary Procedures to the best of my ability. I further understand that ACE certification does notcertify or in any way guarantee the quality of my work as an ACE-certified Professional. I therefore agree to indemnify and hold harmless ACE, its officers, directors, and stafffrom any claims due to negligence, omission, or faulty advice that I may give to clients as an ACE-certified Professional. I understand that ACE is not responsible for anyactions or damages from any person arisingout of my work as an ACE-certified Professional.

YES, I have a current CPR certificate I am CPR certified by: Expiration Date: ___________________________________________ AFFIRMATION SIGNATURE

NO, I do not have a current CPR certificate. If you answer No,ACE will not release your examscores until we have received documentation that you have completed your CPR certification

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Clinical Exercise SpecialistApplicant Documentation Form

In order to take the Clinical Exercise Specialist Certification Exam, you must have 300 hours of work experience designing and implementing exercise programs for apparentlyhealthy individuals and/or high-risk individuals, as documented by a qualified professional.

Clinical Exercise Specialist candidates must submit the following additional documentation:[_] Completed Applicant Documentation Form by a qualified professional

[_] Photocopy of either A) Diploma, transcripts or other documentation on university/college letterhead or B) Copy of fitness certificationIf petitioning, a total of three (3) Applicant Documentation Forms must be submitted

Name of Applicant:(Last, First, Middle or Initial)

TO THE APPLICANT: Only QUALIFIED Professionals (i.e., allied health professionals, fitness directors, club managers, professors or teachers) maycomplete this portion of the form.Evaluator Name:

Title:

Organization:

Address:

City: State: ZIP: Day Phone: Evening Phone: Email:

Licences/Certifications Held:

Degrees Held:

Please describe what qualifies the candidate for this exam.Please comment on candidate's experience with respect to: 1. Screening, 2.Assessment, 3. Programming, 4. Exercise Leadership (Please attach additional information as needed.)

I attest that the above named applicant, to best of my knowledge, has at least 300 hour of experience designing and implementing exercise and physicalactivity programs for apparently healthy individuals and/or those with health challenges who have been cleared by their physician. I understand that I will notbe held responsible for any actions from the applicant arising from the application process for the ACE certification exams nor work as an ACE-certifiedProfessional.

EVALUATOR'S SIGNATURE: Date: