NACM Brochures 2015 NACM Professional Certification Program - Page 14

Application for the Certified Credit Executive® (CCE®) Designation Online CCE Application Form Applicant Information Mr./Ms. First Name Middle or Maiden Name Last Name Name as should appear on all correspondence and certificate Title Business Email Address Company Business Mailing Address City State Zip Business Shipping Address City State Zip Direct Business Telephone Main Business Telephone Direct Business Fax Main Business Fax Home Address City State Zip Home Telephone Home Email Address Birth Month/Day (MM/DD) ________________ The name of my local NACM Affiliate: ______________________________________ I understand that I must already be registered with the National Education Department. (If you are not already registered, please attach a registration form, with the appropriate fee, to this form.) I understand that a non-refundable fee must accompany this application. This fee covers the CCE® designation process. I further understand that should I fail to complete this process by not taking the exam within one year of my written approval, I will need to reapply. The application fee is not divisible; no part will be refunded should I not complete the process. Application Fee:   q Member: $385   q Non-member: $535 q A check, made payable to NACM-National Education Department, is attached. Charge to: q VISA q MasterCard q American Express Card Number Card Security Code Cardholder’s Name Cardholder’s Signature Credit Card Billing Address Please send all correspondence related to this application to: q Home address q Business address I plan to sit for the CCE exam on the following date: q March 9, 2015 q May 17, 2015 (exam given at NACM’s Credit Congress in St. Louis, MO only) q July 27, 2015 q November 9, 2015 14 q Diners Club q Discover Card Expiration Date