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LICENSED AFFILIATE APPLICATION

And Conditions

Licensed Affiliates (LA) are organizations involved in the delivery of accredited third party training programs in partnership with an Accredited Training Organization (ATO). An approved LA may order ITIL and CPDE certification exams directly from LCS. The LA will be invoiced separately and will receive exam summary results independently of the ATO. Ultimately, the actions of the LA remain the responsibility of the ATOs. The sponsoring ATO and LA must oblige to the following requirements and terms before accreditation may be granted. SECTIONS 1 and 2: The sponsoring ATO must complete sections 1 and 2 of this application. SECTION 1 Name and Address of Sponsoring Accredited Training Organization (ATO): SPONSORING ATO INFORMATION Authorized Representative Name and Email:
(contact person responsible for the information provided in this application and for ensuring compliance with LCS requirements)

Telephone:

SECTION 2

APPROVED COURSES TO DELIVER


Indicate which course materials the LA will be approved to deliver as per the 3rd Party Agreement

Certified Process Design Engineer (CPDE)

ITIL Planning Protection and Optimization (PPO) ITIL Service Offerings and Agreements (SOA) ITIL Release Control and Validation (RCV) ITIL Operational Support and Analysis (OSA) ITIL Managing Across the Lifecycle (MALC) ITIL Continual Service Improvement (CSI) English French Spanish Other________________________________ Yes No

ITIL Foundation ITIL Service Strategy (SS) ITIL Service Design (SD) ITIL Service Transition (ST) ITIL Service Operation (SO) In which language(s) will the training be delivered? Confirm the LA maintains compliance with the sponsoring ATOs Quality Management System.

ITIL is a Registered Trade Mark of the Cabinet Office CPDE is a Registered Trade Mark of ITSM Academy Inc.

Form: ACAP-009 Issue Date: 9-May-08

Revision Date: 22-Jan-13 Revision #: 12

LICENSED AFFILIATE APPLICATION


And Conditions

SECTIONS 3 and 4: The LA must complete sections 3 and 4 of this application.


SECTION 3 Company Name and Address:
(Please enter COMPANY NAME AND ADDRESS as you wish it to appear on the LCS web site.)

LICENCED AFFILIATE INFORMATION Authorized Representative Name and Email:


(Contact person responsible for the information provided in this application and for ensuring compliance with the requirements of LCS Accreditation)

Telephone: Ordering Contact and Email Address: (This is the contact


person responsible for the ordering of all ITIL and CPDE exams with LCS)

Mailing/Billing Address:
(same as above or indicate below)

Accounts Payable Contact Name and Email Address:


(This is the contact person responsible for ensuring financial viability is in good standings)

Website: Confirm the LA maintains compliance with the sponsoring ATOs Quality Management System.

Telephone: Yes

Fax: No

SECTION 4

LIST OF TRAINERS
Please provide a complete list of all trainers that will conduct courses on behalf of the LA.

Name of Trainer(s)

Name of Trainer(s)

Please confirm if your organization will be utilizing the sponsoring ATOs qualified trainers

Yes

No

ITIL is a Registered Trade Mark of the Cabinet Office CPDE is a Registered Trade Mark of ITSM Academy Inc.

Form: ACAP-009 Issue Date: 9-May-08

Revision Date: 22-Jan-13 Revision #: 12

LICENSED AFFILIATE APPLICATION


And Conditions

SECTION 5:
The LA must complete Section 5 of this application and provide the applicable documentation below. Please be sure to read and understand the following requirements that must be fulfilled by your organization. Failure to follow these requirements, LCS may not be able to provide accreditation to your organization. If you need additional clarification, please contact accreditation@loyalistexams.com

SECTION 5

SUBMISSION CHECKLIST
Licensed Affiliate Application Form (ACAP-009) is completed. Copy of Third Party Agreement signed by both parties indicating the terms and the applicable ITIL and CPDE courses the LA is approved to deliver. Quality Management System - Must be in compliance with ATOs Quality Management System. (Please be sure you have checked this off in section 3 on this application form) Marketing Materials or URL is in-line with the Official Accreditor IPR Guidelines. LCS will contact the LA 20 business days after becoming accredited to confirm this requirement is fulfilled. Payment in full or Payment Arrangements made with LCS. Trainer Requirements: a) Resume/CV - with the following requirements: Minimum of 3 years ITSM practical experience At least 10 days experience delivering classroom based training within the past 24 months Adult education experience/certification b) Proof of ITIL and CPDE Certifications achieved (minimum of 9 ITIL credits). c) Trainer e-mail address LCS requires the trainers e-mail address to enter them into our system as a qualified trainer. *** ITIL LA Intellectual Property Sub-License Agreement and Fee completed

***ITIL LA Intellectual Property Sub-License Agreement:


LCS cannot grant approval until this agreement has been signed and sent back to The Official Accreditor. As an Examination Institute, LCS is required to advise the Official Accreditor of any new LA relationships. This requirement is completed by LCS, before approval can be granted. New applicants need to be aware when their application is submitted, LCS will contact The Official Accreditor requesting for an IP Sub-License to be generated. The Official Accreditor will send, via e-mail, the ITIL LA Intellectual Property Sub-License Agreement to the new applicant. The Official Accreditor will be using this electronic method to issue licenses to all applicants to ensure fast and guaranteed receipt and return of IP licenses. Please look in your inbox for an e-mail from EchoSign to find this IP Sub-License agreement. This IP Sub-License allows the LA to use the LA logo, Trademarks and Copyright within their marketing materials. This agreement must be signed and sent back to The Official Accreditor before approval may be granted.

Once the license has been completed, The Official Accreditor will advise LCS and we can proceed with the approval process. The Official Accreditor will then invoice the LA. Should the LA fail to follow these requirements, The Official Accreditor will inform LCS to suspend ordering privileges until this requirement is resolved.

ITIL is a Registered Trade Mark of the Cabinet Office CPDE is a Registered Trade Mark of ITSM Academy Inc.

Form: ACAP-009 Issue Date: 9-May-08

Revision Date: 22-Jan-13 Revision #: 12

LICENSED AFFILIATE APPLICATION


And Conditions

CONDITIONS FOR ACCREDITATION Licensed Affiliate (LA) shall:


1) 2) Comply at all times with the criteria, accreditation guide and conditions for accreditation as set out by LCS; Accredited ITIL and CPDE training is delivered as provided by the ATO, without changes or modification and ensure compliance with ATOs Quality Management System at all times. Comply with the requirements of LCS, the Cabinet Office as the owner of ITIL and the Official Accreditor for ITIL, in making reference to its accreditation status in communication media such as advertising, brochures or other documents. Marketing materials and student handouts meet the requirements of the IPR Guidelines, set out by the Official Accreditor. Only claim accreditation status in respect of services for which it has been granted accreditation and which are carried out in accordance with these conditions. Not conduct any advertising with regards to their accreditation status until accreditation has been granted by LCS. Not use its accreditation in such a manner as to bring LCS into disrepute or make any statement relevant to its accreditation which LCS may consider misleading or unauthorized. Endeavor to ensure that no report or logo, nor any part thereof, is used in a misleading manner. Pay invoices to LCS on a timely basis, within 30 days of receipt. Should the LA default on payments of invoices issued by LCS in excess of 90 days, services to the LA will be suspended until payment has been received in full or payment arrangements have been made with LCS. Inform LCS within 30 days and in writing of changes in any aspect of the licensed affiliates status or operation that affects the organizations policies or procedures, where appropriate; resources, where significant; authorized signatories; or such other matters that may affect the licensed affiliates capability, or scope of accredited activities, or compliance with the criteria, requirements and conditions for accreditation; A LA may voluntarily terminate its accreditation at any time by providing written notice to LCS. Upon expiration, withdrawal or suspension of its accreditation (however determined) discontinue the use of all advertising material that contains reference thereto of accreditation and return any certificates of accreditation to LCS.
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A Licensed Affiliate AUTHORIZED REPRESENTATIVE is responsible for ensuring that all of the relevant conditions for accreditation are met. In order to apply, the applicants AUTHORIZED REPRESENTATIVE, must agree to the above conditions for accreditation and must attest that all statements made on the application are correct to the best of his/her knowledge and belief. As the applicants AUTHORIZED REPRESENTATIVE, to attain and maintain accreditation, I agree to the above conditions for accreditation. I attest that all statements made on this application are correct to the best of my knowledge and belief. I have read and understand the LCS Accreditation Guide and the above Conditions for Accreditation and agree with the rights and responsibilities as described in these documents. AUTHORIZED REPRESENTATIVE: PRINTED NAME AND TITLE: DATE:
ITIL is a Registered Trade Mark of the Cabinet Office CPDE is a Registered Trade Mark of ITSM Academy Inc.

Form: ACAP-009 Issue Date: 9-May-08

Revision Date: 22-Jan-13 Revision #: 12

LICENSED AFFILIATE APPLICATION


And Conditions

Accredited Training Organization (ATO) shall:


1) Inform LCS in writing within 30 days of changes regarding the third party agreement in place with the Licensed Affiliate (LA) or in any aspect of the LAs status or operation that affects the organizations policies or procedures, where appropriate; resources, where significant; authorized signatories; or such other matters that may affect the LAs capability, or scope of accredited activities, or compliance with the criteria, requirements and conditions for accreditation; 2) Provide notice in writing to LCS of the voluntary termination of accreditation. Upon expiration, withdrawal or suspension of its accreditation (however determined) discontinue the use of all advertising material that contains reference thereto of accreditation and return any certificates of accreditation to LCS; 3) Ensure the LA is in compliance with the Quality Management System of the ATO. 4) Ensure the LA is in compliance with the marketing requirements and the IPR Guidelines set-out by the Official Accreditor. 5) Ensure the LA is only advertising ITIL and CPDE training for which the ATO has been granted accreditation for. 6) To maintain current accreditation status with an accredited Examination Institute. An Accredited Training Organizations (ATOs) AUTHORIZED REPRESENTATIVE is responsible for ensuring that all of the relevant conditions for accreditation are met. In order to apply, the applicants AUTHORIZED REPRESENTATIVE, must agree to the above conditions for accreditation and must attest that all statements made on the application are correct to the best of his/her knowledge and belief. As the applicants AUTHORIZED REPRESENTATIVE, to attain and maintain accreditation, I agree to the above conditions for accreditation. I attest that all statements made on this application are correct to the best of my knowledge and belief. I have read and understand the LCS Accreditation Guide and the above Conditions for Accreditation and agree with the rights and responsibilities as described in these documents. AUTHORIZED REPRESENTATIVE: PRINTED NAME AND TITLE: DATE:
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ITIL is a Registered Trade Mark of the Cabinet Office CPDE is a Registered Trade Mark of ITSM Academy Inc.

Form: ACAP-009 Issue Date: 9-May-08

Revision Date: 22-Jan-13 Revision #: 12

LICENSED AFFILIATE APPLICATION


And Conditions

Loyalist Certification Services (LCS) shall:


1) Reserve the right to withdraw accreditation from the Accredited Training Organization and/or the Licensed Affiliate (LA) at any time if it is deemed that conditions of accreditation are not being met. Advise the LA in writing of any changes in the status of the Accredited Training Organization that may affect the accreditation status of the LA. Provide via email quarterly Activity Summary Reports to both the ATO and the LA which will detail the exam sessions held during that quarter, the type of exams delivered, the number of exams processed, the trainer name and the class average of each session.

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As the AUTHORIZED REPRESENTATIVE of LCS, I agree with the rights and responsibilities as described in the LCS Accreditation Guide and to the above conditions for accreditation. I attest that all statements made on this application are correct to the best of my knowledge and belief. AUTHORIZED REPRESENTATIVE: PRINTED NAME AND TITLE: DATE:

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Authorized Representative is: an official who represents the organization in all matters related to attaining and maintaining LCS Accreditation. This official is LCSs point of contact with the organization. The Authorized Representative may be any senior person in th e organization and he or she should be in a position of authority to ensure that the organization complies with the LCS criteria and conditions for accreditation.

ITIL is a Registered Trade Mark of the Cabinet Office CPDE is a Registered Trade Mark of ITSM Academy Inc.

Form: ACAP-009 Issue Date: 9-May-08

Revision Date: 22-Jan-13 Revision #: 12