IRPS Council Application • Via Hope

Via Hope has launched the International Reentry Peer Specialist® Certification. We are excited to be convening a council to provide general guidance and to investigate and take appropriate action on all ethical complaints or violations as required. The Council will consist of 7 individuals (two Via Hope staff members). The majority of the council members will have incarceration lived experience and some will not. The council members will meet quarterly unless there are ethical complaints that need to be addressed. The term of service for each council member will run for 3 years. Please fill out the application below to apply to be a council member of the IRPS.

Your application will be reviewed and a Via Hope staff member will be in touch with a decision. Thank you in advance for your willingness to serve.

IRPS Advisory Council

Name*
First M.I. Last
Home Address:*
Street Address Address Line 2 City State ZIP Code
Home / Primary Phone Number:*
Cell / Secondary Phone Number:*
Email Address:*
What organization(s) provided your training?
Organization Name:*
Address:*
Street Address Address Line 2 City State ZIP Code
Contact Phone Number:*
Contact Email:*
Start date of class:*
Month
Day
Year
End date of class:*
Month
Day
Year
Total Number of Class Hours:*
When did your certification begin?*
Month
Day
Year
Is your certification still active?*
- Yes
- No
Who was your most recent employer in the original certification state where you worked as a Certified Peer Specialist?
Organization Name:*
Your Title:*
Address:*
Street Address Address Line 2 City State ZIP Code
Supervisor Name:*
Supervisor Title:*
Contact Phone:*
Contact Email:*
Reason for leaving last position:*
Attach a copy of your Certification from the other State and two letters of character reference. If not provided, your application will not be approved.*
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Accepted file types: pdf, Max. file size: 50 MB.
Signature:*
Date:*
MM slash DD slash YYYY
Email
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IRPS Advisory Council

What organization(s) provided your training?

Who was your most recent employer in the original certification state where you worked as a Certified Peer Specialist?

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