NACM Brochures 2017 NACM Professional Certification Program - Page 11

Application for the Credit Business Associate SM (CBA SM ) Designation Testing Location The exam will be given at your local affiliated association office unless special, advanced arrangements are made. If you wish to test at a location different from your affiliate office (must be approved by NACM), please provide proctor information below. Proctors must be in a supervisory role or a human resource representative from your company. Proctor Name Proctor Title Shipping Address (street address only) Email Phone q C  heck here if upon receiving the CBA SM designation, you would like NACM to notify your immediate supervisor (only one name please) of your achievement. The NACM president should send the notification to: Mr./Ms. Name of Supervisor Supervisor’s Title Company Mailing Address City State/Province Direct Phone Zip/Postal Code Country Email Address I hereby apply for admission to the Credit Business Associate SM (CBA SM ) Designation. I understand that I must take and pass the CBA SM exam before achieving this designation. I have met all of the requirements for this designation as outlined in the NACM Professional Certification brochure. By my signature, I agree to uphold the NACM Canons of Business Credit Ethics with the knowledge that any false statement or misrepresentation that I make in the course of these proceedings may result in the revocation of this application, forfeiture of the application fee and prohibit me from participating in the Professional Certification Program. I further agree to conduct myself in all business dealings so as to reflect honor and merit upon the financial and business credit profession. Signature of Applicant Date I understand that by providing my mailing address, email and telephone number, i consent communications sent by or on behalf of the National Association of Credit Management (NACM), FCIB-NACM, Inc., and its subsidiaries and Affiliated organizations, via regular mail, or telephone. Signature of Applicant Date q Check here to opt out of the congratulatory listing published in Business Credit magazine. Return completed form to: NACM Education Dept., 8840 Columbia 100 Parkway, Columbia, MD 21045-2158 • Fax: 410-740-5574 • Email: 11